The Spectrum of Adrenal Lesions in a Tertiary Referral Center.

BACKGROUND: Adrenal tumors are a common finding in clinical practice, and only detailed evaluation may reveal secretory and metabolic abnormalities or their malignant character. We aimed to highlight epidemiological data, rates of malignancy, clinical or secretory characteristics, and the cardiometabolic implications of adrenal masses. METHODS: We conducted a retrospective analysis using data from the medical files of 474 patients with adrenal pathology hospitalized between January 2007 and January 2020, before the COVID-19 pandemic, using the ICD-10 codes. After applying inclusion and exclusion criteria, a total of 264 patients with adrenal tumors were enrolled in the study. Patients underwent clinical examination, abdominal imaging, and hormonal evaluation, and some of them underwent a pathological exam after adrenalectomy. RESULTS: Median age at diagnosis was 56 (17) years, with 81.06% of patients being female. The median follow-up period was 41.5 (70) months, ranging from 6 months to 13 years. Adrenal tumors were most frequently seen in older female patients, with 83.47% of them being over 40 years old. The malignancy rate was 4.54%. Hormonally nonfunctioning tumors (71.95%) predominated, and overt hypercortisolism was present in 10.61% of patients, as was mild autonomous cortisol secretion in 5.31% of patients, primary hyperaldosteronism in 8.71% of patients, and adrenal paraganglioma in 3.41% of patients. Cardiometabolic comorbid conditions were similar in patients with functioning and nonfunctioning tumors. CONCLUSIONS: All patients with adrenal tumors should receive a complete hormonal workup and detailed malignancy risk assessment. Even though a hormonally active tumor predisposes to cardiometabolic comorbid conditions, a nonfunctioning lesion may also be associated with such disorders and needs thorough assessment.

Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis.

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision.

Surface pre-treatment of aluminum alloy for mechanical improvement of adhesive bonding by maple-assisted pulsed laser evaporation technique.

Adhesive joints are widely used for structural bonding in various industrial sectors. The performance of bonded joints is commonly attributed to the cleanliness of the substrate and the pre-treatment of the surfaces to be bonded. In this study, the Matrix Assisted Pulsed Laser Evaporation (MAPLE) deposition technique was used for surface modification of aluminum (Al) plates by the deposition of poly(propylene glycol) bis(2-aminopropyl ether) (PPG-NH2) of different number average molecular weights (Mn) of 400 g mol-1, 2000 g mol-1, and 4000 g mol-1, respectively. Fourier-transformed infrared spectroscopy (FT-IR) analysis indicated the characteristic peaks for the deposited layers of PPG-NH2 of different molecular weights in all cases while scanning electron microscopy (SEM) revealed continuous layers on the surface of Al plates. In order to demonstrate alterations in the wettability of Al substrates, a crucial aspect in surface treatment and adhesive bonding, measurements of contact angles, surface free energies (SFE), and adhesion work (W a) were conducted. The tensile strength measurements were performed using the lap-joint test after applying the commercial silyl-based polymer adhesive Bison Max Repair Extreme Adhesive®. It was evidenced that at higher values of the SFE and W a, the tensile strength was almost 3 times higher for PPG-NH2 with Mn = 4000 g mol-1 compared with the untreated Al sample. This study provides valuable insights into the successful application of the MAPLE technique as a pre-treatment method for reinforcing adhesive bonding of Al plates, which can lead to improved mechanical performance in various industrial applications.

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors.

BACKGROUND: Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain. METHODS: We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor. RESULTS: Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor. CONCLUSIONS: The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

Complicated Liver Cystic Echinococcosis-A Comprehensive Literature Review and a Tale of Two Extreme Cases.

Cystic echinococcosis is a zoonotic parasitic disease that affects the liver in more than 70% of cases, and there is still an underestimated incidence in endemic areas. With a peculiar clinical presentation that ranges from paucisymptomatic illness to severe and possibly fatal complications, quality imaging and serological studies are required for diagnosis. The mainstay of treatment to date is surgery combined with antiparasitic agents. The surgical armamentarium consists of open and laparoscopic procedures for selected cases with growing confidence in parenchyma-sparing interventions. Endoscopic retrograde cholangiopancreatography (ERCP) is extremely useful for the diagnosis and treatment of biliary fistulas. Recent relevant studies in the literature are reviewed, and two complex cases are presented. The first patient underwent open surgery to treat 11 liver cysts, and during the follow-up, a right pulmonary cyst was diagnosed that was treated by minimally invasive surgery. The second case is represented by the peritoneal rupture of a giant liver cyst in a young woman who underwent laparoscopic surgery. Both patients developed biliary fistulas that were managed by ERCP. Both patients exhibited a non-specific clinical presentation and underwent several surgical procedures combined with antiparasitic agents, highlighting the necessity of customized treatment in order to decrease complications and successfully cure the disease.

Antimicrobial Biomaterials for Chronic Wound Care.

Chronic wounds encompass a myriad of lesions, including venous and arterial leg ulcers, diabetic foot ulcers (DFUs), pressure ulcers, non-healing surgical wounds and others. Despite the etiological differences, chronic wounds share several features at a molecular level. The wound bed is a convenient environment for microbial adherence, colonization and infection, with the initiation of a complex host-microbiome interplay. Chronic wound infections with mono- or poly-microbial biofilms are frequent and their management is challenging due to tolerance and resistance to antimicrobial therapy (systemic antibiotic or antifungal therapy or antiseptic topicals) and to the host's immune defense mechanisms. The ideal dressing should maintain moisture, allow water and gas permeability, absorb wound exudates, protect against bacteria and other infectious agents, be biocompatible, be non-allergenic, be non-toxic and biodegradable, be easy to use and remove and, last but not least, it should be cost-efficient. Although many wound dressings possess intrinsic antimicrobial properties acting as a barrier to pathogen invasion, adding anti-infectious targeted agents to the wound dressing may increase their efficiency. Antimicrobial biomaterials may represent a potential substitute for systemic treatment of chronic wound infections. In this review, we aim to describe the available types of antimicrobial biomaterials for chronic wound care and discuss the host response and the spectrum of pathophysiologic changes resulting from the contact between biomaterials and host tissues.

The Curious Case of the Choledochal Cyst-Revisiting the Todani Classification: Case Report and Review of the Literature.

Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case-a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.

Acquired benign tracheo­oesophageal fistula secondary to oesophageal stenting for post lye ingestion stenosis: A case report.

Acquired benign trachea-oesophageal fistula is a rare benign pathological entity with varying aetiologies that most often occurs post-intubation. This case report presents the case of a female patient, 31 years old, admitted to the emergency room with sepsis syndrome following bilateral aspiration pneumonia caused by a large trachea-oesophageal fistula. The fistula was the result of intra-tracheal migration of an oesophageal stent placed for post lye ingestion stenosis. Esophageal diversion and partial resection with oesophageal patch to repair the tracheal defect, under general anaesthesia with ventilation using rigid bronchoscopy and high frequency jet ventilation (HFJV), followed at a later date by esophageal replacement with colic graft were the procedures performed with a view to curing the patient. In conclusion, complex cases always require a tailored approach. It is important to note that HFJV may be applied for a longer period of time and the oesophagus can be used as patch for the posterior tracheal wall in selected cases. Staged surgery is also an option when the patients' poor health status does not permit major surgery.

Multivariate Risk Analysis of RAS, BRAF and EGFR Mutations Allelic Frequency and Coexistence as Colorectal Cancer Predictive Biomarkers.

BACKGROUND: Biomarker profiles should represent a coherent description of the colorectal cancer (CRC) stage and its predicted evolution. METHODS: Using droplet digital PCR, we detected the allelic frequencies (AF) of KRAS, NRAS, BRAF, and EGFR mutations from 60 tumors. We employed a pair-wise association approach to estimate the risk involving AF mutations as outcome variables for clinical data and as predicting variables for tumor-staging. We evaluated correlations between mutations of AFs and also between the mutations and histopathology features (tumor staging, inflammation, differentiation, and invasiveness). RESULTS: KRAS G12/G13 mutations were present in all patients. KRAS Q61 was significantly associated with poor differentiation, high desmoplastic reaction, invasiveness (ypT4), and metastasis (ypM1). NRAS and BRAF were associated with the right-side localization of tumors. Diabetic patients had a higher risk to exhibit NRAS G12/G13 mutations. BRAF and NRAS G12/G13 mutations co-existed in tumors with invasiveness limited to the submucosa. CONCLUSIONS: The associations we found and the mutational AF we reported may help to understand disease processes and may be considered as potential CCR biomarker candidates. In addition, we propose representative mutation panels associated with specific clinical and histopathological features of CRC, as a unique opportunity to refine the degree of personalization of CRC treatment.

Laparoscopic vs. open resection for colon cancer-quality of oncologic resection evaluation in a medium volume center.

Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.

Look beyond the Mirror: Laparoscopic Cholecystectomy in Situs Inversus Totalis-A Systematic Review and Meta-Analysis (and Report of New Technique).

BACKGROUND: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. METHODS: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. RESULTS: Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. CONCLUSIONS: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.

Treatment of Achalasia in the Evidence-Based Medicine Era - A Quest in Search for a Proper Attitude by Reviewing the Present Guidelines.

The best way to start a paper like this is with a citation from W. Edwards Deming: Without data, you're just another person with an opinion. In the era of Evidence-Based Medicine (EBM) every surgical procedure has to be backed up by solid statistical data to offer our patients the best treatment. But is EBM always the path to truth? We decided to analyze the literature for achalasia and see if the guidelines and the data are reliable enough to justify a certain attitude. Practically, we engaged in this endeavor not because we do not trust the statements of the guidelines, but to see if a surgeon can find by themselves the proper attitude in this disease. Achalasia is a motility disorder of the esophagus characterized by deficient relaxation of the inferior esophageal sphincter that results in dysphagia. There are several methods of treatment, with various statements in the guidelines. Currently, every treatment should be sustained by data and statistics, evidence-based medicine being mandatory when a method is preferred over another. This article reviews several studies and also the available guidelines in search for an answer to the question which procedure is the best.

Posterior Circular Stapled GastroJejunostomy After Duodenopancreatectomy.

Anastomotic fistulae are the most common and dreaded postoperative complications of pancreaticoduodenectomy. Delayed gastric emptying (DGE) and slow recovery of bowel function are contributing causes for postoperative pancreatic fistula (PoPF) that should be taken into consideration. The present study evaluates data from 17 consecutive cases that underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with pancreaticojejunal anastomosis and circular stapled mechanical gastrojejunal anastomosis instead of the standard terminolateral technique. Three patients developed Grade A DGE (one also developed grade B PoPF) and one patient required reinsertion of the nasogastric tube due to Grade B PoPF. Overall, the incidence of DGE was 23.5%. Three patients developed Grade B pancreatic fistulae that were successfully managed conservatively. Twelve patients resumed early bowel movement within 4 days, two reinterventions were required for postoperative bleeding. Mean hospital stay was 11.5 days. Patients with DGE had a mean hospital stay of 14.5 days. No gastrojejunostomy leak was encountered. Mortality was nil. Therefore we consider the posterior circular stapled gastrojejunostomy a simple, reproducible, safe technical alternative for avoiding DGE and consequently help lower the risk of PoPF, increased costs associated with prolonged hospital stay and an improved postoperative quality of life.

How Many Times Can One Go Back to the Drawing Board before the Accurate Diagnosis and Surgical Treatment of Glucagonoma?

Glucagonomas are neuroendocrine tumors (NETs) that arise from the alpha cells of the pancreatic islets. They are typically slow-growing tumors associated with abnormal glucagon secretion, resulting in one or more non-specific clinical features, such as necrolytic migratory erythema (NME), diabetes, diarrhea, deep vein thrombosis, weight loss, and depression. Here, we report the case of a 44-year-old male with a history of diabetes mellitus, presenting with a pruritic and painful disseminated cutaneous eruption of erythematous plaques, with scales and peripheral pustules, misdiagnosed as disseminated pustular psoriasis and treated for 2 years with oral retinoid and glucocorticoids. During this period, the patient complained of weight loss of 32 kg and diarrhea and developed deep vein thrombosis. These symptoms, together with an inadequate response to therapy of the skin lesions, led to the reassessment of the initial diagnosis. Laboratory tests confirmed elevated plasma glucagon levels (>1000 pg/mL) and computed tomography (CT) scans revealed a 35/44 mm tumor in the pancreatic tail. Due to considerable disease complications and the COVID-19 pandemic, the surgical removal of the tumor was delayed for nearly 2 years. During this time, somatostatin analogue therapy efficiently controlled the glucagonoma syndrome and likely prevented tumor progression. As in other functional pancreatic NETs, the early clinical recognition of hormonal hypersecretion syndrome and the multidisciplinary approach are the keys for best patient management.

Overview of the anatomical basis of the piriformis syndrome-dissection with magnetic resonance correlation.

The piriformis syndrome is one of the most commonly misdiagnosed causes of lower back and gluteal pain caused by the compression of the sciatic nerve and the internal pudendal neurovascular bundle by the piriformis muscle. Although this syndrome was first suggested over 90 years ago, its diagnosis still represents a challenge for clinicians. In the present study, dissection was used to determine the intra- and extrapelvic anatomical course of the internal pudendal nerve and the data were compared with the information obtainable through MRI examination, in order to identify the piriformis syndrome and to differentiate it from other causes of internal pudendal neuralgia. Thorough dissections of the pelvis and deep gluteal region were conducted on female cadavers, which were correlated with MRI scans, in order to describe the course of the internal pudendal nerve in contact with the piriformis muscle. The dissection findings and MRI scans obtained allowed us to describe and demonstrate the compression points along the course of the sciatic nerve and the internal pudendal bundle, the anatomical correlations between the piriformis muscle and the nervous structures around it, emphasizing the areas most susceptible to possible nerve impingement syndromes. In the anatomic trajectory of the sciatic nerve and the internal pudendal bundle there are multiple contact points with anatomical structures that may lead to compression of the nerve structures, generating symptoms that comprise the piriformis syndrome. The present study sought to establish clear osseous landmarks that may help evaluate these associations and possible nerve compressions on pelvic MRI examination.

Clinical Impact of the Administration of FOLFIRINOX Beyond Six Months in Advanced Pancreatic Adenocarcinoma: A Cohort Study.

Background Although a toxic regimen, FOLFIRINOX is one of the most efficient chemotherapy regimens in advanced pancreatic adenocarcinoma. There is no standard number of cycles in locally advanced or metastatic stages. Materials and method The present retrospective study reports the experience of a single center with this regimen administered until disease progression or unacceptable toxicity. The authors of this retrospective study analyzed the data on patients with this diagnosis treated in our clinic during 2017-2021. Forty-two patients were included in the study, 21 who received six courses or less and 21 who received more than six courses. Progression-free survival (PFS) and overall survival (OS) were analyzed according to this stratification. The oncological response was also reported according to dose reduction and treatment delay, irrespective of the number of courses administered. Results Median PFS was 7.5 months, and median OS was 13.6 months in the entire studied population. When patients were compared according to the number of courses received (under six vs. over six), there were obvious differences (PFS: 5.17 months vs. 11.2, p = 0.8, OS: 8 months vs. 17.3 months, p = 0.6). However, when stratifying survival by treatment delay and the presence or absence of dose reduction, better results were seen with lower doses (p<0.001) and treatment temporization (p=0.03). The general incidence of hematologic and neurologic toxicity was higher than the ones reported in the literature. Conclusion The study revealed that patients benefit from the administration of FOLFIRINOX for more than six months, but that the administration of full dose and the maintaining dose intensity does not necessarily favor the patient.

Platelet Activation and Inflammation in Patients with Papillary Thyroid Cancer.

BACKGROUND: The primary endpoint was to analyze the preoperatory inflammatory markers and platelet indices in papillary thyroid cancer (PTC) patients compared with patients with benign thyroid pathology. The secondary endpoints were to analyze the relationship between these markers and the pathological features of PTC and to compare their pre- and postoperative levels in PTC patients. METHODS: In this retrospective case-control study, we analyzed the files of 1183 patients submitted to thyroidectomy between January 2012 and December 2018. A total of 234 patients with PTC (mean age 51.54 ± 13.10 years, 84.6% females) were compared with an age-, gender- and BMI-matched control group of 108 patients with histologic benign thyroid disorders. RESULTS: PTC patients had higher platelet count (PLT) (p = 0.011), plateletcrit (PCT) (p = 0.006), neutrophil (p = 0.022) and fibrinogen (p = 0.005) levels. Subgroup analysis showed that PTC females had higher PLT (p = 0.006), PCT (p < 0.001) and erythrocyte sedimentation rate (ESR) (p = 0.005), while males had higher neutrophil (p = 0.040) levels. Papillary thyroid cancer patients under 55 years had higher PLT (p < 0.001) and PCT (p = 0.010), while patients over 55 years had higher mean platelet volume (p = 0.032), neutrophil-to-lymphocyte ratio (p = 0.013), ESR (p = 0.005) and fibrinogen (p = 0.019) levels. Preoperative values for platelet indices and inflammatory markers were similar to the postoperative determinations in PTC patients. Fibrinogen (AUROC = 0.602, p = 0.02; cut-off = 327.5 mg/dL, Se = 53.8%, Sp = 62.9%) and PLT (AUROC = 0.584, p = 0.012; cut-off = 223.5 × 103/mm3, Se = 73.1%, Sp = 42.6%) were independent predictors of the presence of PTC. CONCLUSIONS: Our data show that fibrinogen and platelet count could be promising, inexpensive, independent predictors for the presence of PTC when compared with benign thyroid disorders.

Takotsubo syndrome during surgery for pheochromocytoma: an unexpected complication.

Takotsubo syndrome is a rare cause of systolic dysfunction and can be found as a clinical manifestation of pheochromocytoma. We present a case of rapid onset of systolic dysfunction with cardiogenic shock, which developed after the surgical excision of an adrenal gland tumor in a 60-year-old male. Coronary angiography excluded coronary artery disease. The echocardiography and ventriculography images suggested Takotsubo cardiomyopathy pattern. Following 2 weeks of inotropic and vasopressor therapy, the left ventricular function gradually improved, until complete resolution.

Pathological Response and Survival after Neoadjuvant Therapy for Her-2 Positive Breast Cancer.

Background: Pathological complete response (pCR) after neoadjuvant systemic treatment represents a good surrogate marker for the prognosis of Her-2 positive Breast Cancer (BCs). The results improved after adding anti-Her-2 therapy to chemotherapy in neoadjuvant setting. Methods: Our retrospective study enrolled a cohort of 56 invasive Her-2 positive non-metastatic BCs treated with neoadjuvant systemic therapy between 2001 and 2018. The patients received neoadjuvant chemotherapy with or without anti-Her-2 therapies before surgery and adjuvant endocrine and anti-Her-2 treatment together with adjuvant radiotherapy, based on clinical, pathological and hormonal receptor expression characteristics. The primary end point was pCR rate and disease-free-survival (DFS), defined as the interval between surgery and documented disease recurrence, progression, or death from any cause. Results: The rate of pCR for our patients was 41% independent of type of chemotherapy regimen and the anti-Her-2 therapy used. The results were improved by adding Trastuzumab in the neoadjuvant setting with statistical significance (p = 0.038). Median DFS was 68 months for the entire cohort. The risk of recurrence was higher in the group without pCR after neoadjuvant treatment (52% vs 17%; p = 0.003). 10 patients died (18%), all of them from group without pCR. The prognosis at 36-months was good, with 84% survival chance at 3 years follow-up. Conclusion: Our retrospective study underlines the positive impact of neoadjuvant systemic treatment on pCR rate and on disease-free survival in real-life Her-2 positive breast cancer patients.

Obstructive Jaundice Secondary to Clip Migration in the Common Bile Duct 9 Years after Laparoscopic Cholecystectomy.

Surgical clip migration in the common bile duct with consecutive stone formation is a rare occurrence after laparoscopic cholecystectomy, less than 100 cases being reported so far. We report a case of a 55-year-old woman with obstructive jaundice due to bile duct stone formed around a migrated surgical clip 9 years after laparoscopic cholecystectomy. The patient presented with pain in the upper abdomen and jaundice. Abdominal ultrasound diagnosed dilation of the common bile duct and intrahepatic bile ducts. The diagnosis was confirmed by computed tomography which revealed a metal clip in the distal part of the common bile duct. The patient was managed successfully by endoscopic retrograde cholangiopancreatography (ERCP) and the surgical clip was retrieved using the Dormia basket. The exact mechanism of clip migration is not fully understood but may be explained by local inflammation and ineffective clipping. Although a rare occurrence, clip migration should not be excluded when considering the differential diagnosis of patients presenting with obstructive jaundice or cholangitis after laparoscopic cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips related complications but surgical common bile duct exploration may be necessary.