Virtual hospitals: The future of the healthcare system? An expert consensus.

Today, social and healthcare systems at a global level are facing constant challenges dictated by an increasing mismatch between the demand for care services and the supply of human and economic resources. Such a situation has been exacerbated in the past two years by the Covid-19 pandemic. This has led to an increase in the leverage of digitalisation, which has proved to be a crucial tool for the development and application of new organisational models at both hospital and territorial levels, thus addressing the various criticalities already present in the system. In this sense, the Virtual Hospital has emerged as a potential model for increasing effectiveness and efficiency in delivering sociomedical services. Starting from these premises, an EFTE (estimate, feedback, talk, estimate) approach was used to acquire an expert consensus within a multidisciplinary panel of academics and healthcare managers of the Veneto Region in Italy. This article reports the expert opinion on the possible application of the Virtual Hospital model in the national context, starting from the existing international evidence and good practices, highlighting the potential advantages and barriers to its implementation. Furthermore, the article analyses the most relevant areas of investment for the development of intangible assets and the acquisition of tangible assets necessary for its implementation.

(1) H-MR spectroscopy characterization of the adipose tissue associated with colorectal tumor.

PURPOSE: To investigate colorectal tumor by looking at the lipid tissue around the lesion. Adipose tissue is not only an inert storage system for excess calories, but is involved in several pathological processes linked to tumor development. MATERIALS AND METHODS: We obtained 24 colorectal specimens after surgical excision from patients affected by colorectal cancer at different tumor stages. (1) H-MR spectoscopy (MRS) spectra were collected from two voxels, in proximity of the lesion and far from it, in each specimen with a preclinical scanner. We differentiated patients by pathological tumor stage, and we compared the chemical composition of adipose tissue between patient groups, both close the tumor and far from it. RESULTS: Monounsaturated fatty acids (MUFA) close the lesion are increased at higher tumor stages, while MUFA far from the lesion do not follow this trend. This study is really explorative due to the small numbers of subjects and we are cautious on the interpretation of the results. However, the approach of the present work allows a further insight in the tumor characterization. CONCLUSION: Looking at the lipid tissue around a lesion through (1) H-MRS can return important information regarding its genesis and development.

Proton magnetic resonance spectroscopy: ex vivo study to investigate its prognostic role in colorectal cancer.

BACKGROUND: Proton Magnetic Resonance Spectroscopy (1H MRS) is used for clinical diagnosis in some tumours. The aim of this study is to explore ex vivo the potential of 1H MRS in identifying malignancy through metabolic markers in the perspective of its application in all cases of difficult diagnosis and after neoadjuvant treatment. METHODS: Spectroscopy was performed ex vivo on 29 colorectal specimens. All patients were staged with imaging, underwent radical surgery and then followed-up. Spectral quantification analysis of components expressed in colorectal tumours and in healthy mucosa were evaluated. The MRS-tumour marker (MRS-tm) was calculated for each case. The U-test was used to compare MRS-tm in tumours and in healthy mucosa. In order to select a cut-off for MRS-tm in the tumour and healthy mucosa and to distinguish patients who were disease-free or with recurrence-progression, we performed the ROC curve analysis. RESULTS: In the 24 subjects without neoadjuvant treatment, it was found that MRS-tm is able to discriminate healthy and neoplastic tissue and can discriminate patients with risk of recurrence/progression CONCLUSION: Our data seem to show that 1H MRS may be successfully applied in vivo non-invasively to differentiate tumours from healthy mucosa and could also distinguish patients with different prognoses.

Neoadjuvant therapy with weekly docetaxel and cisplatin, 5-fluorouracil continuous infusion, and concurrent radiotherapy in patients with locally advanced esophageal cancer produced a high percentage of long-lasting pathological complete response: a phase 2 study.

BACKGROUND: This phase 2 study was aimed at defining the pathological response rate of a neoadjuvant schedule including weekly docetaxel and cisplatin, continuous infusion (c.i.) of 5-fluorouracil (5-FU) and concomitant radiotherapy (RT) in untreated stage II-III adenocarcinoma and squamous cell carcinoma of mid-distal thoracic esophagus. METHODS: The schedule consisted of a first phase of chemotherapy alone and of a second phase of concurrent chemoradiation. Doses were as follows: docetaxel 35 mg/m(2) and cisplatin 25 mg/m(2) on days 1, 8, 15, 29, 36, 43, 50, and 57 plus 5-FU c.i. (180 mg/m(2) on days 1-21 and 150 mg/m(2) on days 29-63); RT (50 Gy) started at day 29. Surgery was planned 6 to 8 weeks after the completion of chemoradiation. RESULTS: A total of 74 patients were enrolled; pathological complete remission (pCR) was found in 47% (35 of 74) and near pCR (microfoci of tumor cells on the primary tumor without lymph nodal metastases) (pnCR) in 15% of the patients (11 of 74). Grade 3-4 neutropenia, nonhematological toxicity, and toxic deaths occurred in 13.5%, 32.4%, and 4% of the patients, respectively. Median follow-up was 55 months (range, 3-108 months). Median survival of all 74 patients was 55 months, whereas it was not reached in the pCR subset. The 3- and 5-year survival rates were, respectively, 83% and 77% for pCR, 73% and 44% for pnCR, and 21% and 14% for Residual Tumor subsets (P < .001). CONCLUSIONS: This study shows that 1) this intensive weekly schedule produced a high pathological response rate, 2) responders had high and long-term durable survival rates.

Extended staging of oesophageal cancer using FDG-PET - a critical appraisal.

BACKGROUND AND AIM: Oesophageal cancer (OC) is a highly aggressive tumour with unfavorable prognosis due to early stages metastases. Treatment and survival rates are highly correlated with tumour wall invasion, lymphatic involvement and metastatic spread. Thus, an accurate staging at initial diagnosis is fundamental for optimal management. In the present review article the potential role of the FDG-PET in the staging of OC is discussed. METHODS: A systematic review of all papers published in PubMed until June 2010 was performed. RESULTS: Endoscopic ultrasound (EUS) is helpful for T and N staging but not for M staging. CT plays a complementary role to EUS in T staging, especially in excluding T4 disease. However, in N staging, CT relies on "size criteria" (<1cm=benign, >1cm=malignant) which reduces its sensitivity and specificity. FDG-PET has been demonstrated to be a very helpful tool in staging and re-staging OC. Most OCs demonstrate high FDG accumulation and are usually well detected with PET. Unfortunately, PET cannot reveal very small lesions due to its limited spatial resolution, therefore limiting the usefulness of PET in T staging. In N staging, an FDG positive node is highly likely to contain disease. However, FDG-PET cannot reliably separate the primary site from closely adjacent nodes. The real and unquestionable additional diagnostic value of FDG-PET in comparison to CT and EUS is in evaluating distant metastases. CONCLUSIONS: It appears reasonable to include FDG PET/CT in the diagnostic algorithm of patients with OC in order to better define the optimal therapeutic approach.

Treatment for retained [corrected] common bile duct stones during laparoscopic cholecystectomy: the rendezvous technique.

OBJECTIVE: To determine the feasibility and efficacy of the laparoscopic intraoperative rendezvous technique for common bile duct stones (CBDS). DESIGN: Case series. SETTING: Verona University Hospital, Verona, Italy. PATIENTS: A total of 110 patients were enrolled in the study; 47 had biliary colic; 39, acute cholecystitis; 19, acute biliary pancreatitis; and 5, acute biliary pancreatitis with associated acute cholecystitis. INTERVENTIONS: In all patients, CBDS diagnosis was reached by intraoperative cholangiography. Intraoperative endoscopy with rendezvous performed during laparascopic cholecystectomy for confirmed CBDS; for such a procedure, a transcystic guide wire was positioned into the duodenum. Intraoperative endoscopy with rendezvous was performed for retrieved CBDS during a laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Laparoscopic rendezvous feasibility, morbidity, postprocedure pancreatitis, and mortality. RESULTS: The laparoscopic rendezvous proved to be feasible in 95.5% (105 of 110 patients). The rendezvous failed in 3 cases of successfully performed laparoscopic cholecystectomy, and a conversion of the laparoscopy was needed in 2 cases of successful rendezvous. Two major complications and 2 cases of bleeding were registered after sphincterotomy was successfully performed with rendezvous, and severe acute pancreatitis complicated a traditional sphincterotomy performed after a failed rendezvous. CONCLUSIONS: Rendezvous is a feasible option for treatment of CBDS; it allows one to perform only 1 stage of treatment, even in acute cases such as cholecystitis and pancreatitis. Positioning of the guide wire may allow reduced complications secondary to papilla cannulation but not those of the endoscopic sphincterotomy.

Real-time polymerase chain reaction quantification of free DNA in serum of patients with polyps and colorectal cancers.

BACKGROUND: Colorectal cancer (CRC) is one of the most frequent causes of cancer related deaths worldwide. Recently, the use of cell-free DNA as diagnostic tools to identify cancer has been investigated. The aim of this work was to assess whether circulating DNA could be considered a useful marker for detection of early stage CRC and polyps. METHODS: A total of 118 patients with CRC were included in the study along with 49 patients with colorectal polyps and 26 control subjects. Cell-free DNA was quantified using a real-time TaqMan-polymerase chain reaction assay. Non-parametric tests (Mann-Whitney test and Spearman correlation) were utilized for statistical analysis. RESULTS: Serum DNA concentrations were significantly higher in CRC patients and patients with polyps (median value 105.0 ng/mL and 40.0 ng/mL) compared with controls (median value 14.0 ng/mL; p<0.05). Although carcinoembryonic antigen was above the cut-off in only 13/66 (19.7%) patients with early stage CRC, serum free DNA showed values above the threshold identified using receiver operator characteristic (ROC) curve analysis in 53/66 (80.3%) patients. CONCLUSIONS: Our data confirm that serum DNA concentrations are significantly increased in CRC patients with early stage disease and in patients with polyps. This marker might be useful for identifying high-risk individuals.

Additional value of FDG-PET/CT in management of "solitary" liver metastases: preliminary results of a prospective multicenter study.

BACKGROUND AND AIM: The most common malignancy affecting the liver is metastasis from a wide variety of tumors, particularly those of gastrointestinal origin. Successful surgical removal of a solitary liver metastasis may significantly extend survival and optimal preoperative assessment in this regard is a mandatory prerequisite for proper patient selection. The addition of positron emission tomography/computed tomography (PET/CT) to other more conventional imaging procedures (e.g., ultrasound (US), CT, and magnetic resonance) has the potential to greatly improve the selection process by the combination of high-resolution anatomy afforded by CT directly combined with the functional scintigraphic map of intra- and extrahepatic lesions depicted by 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-PET. In this study, we assess the additional value of PET/CT in the management strategy of patients with solitary liver metastasis from colorectal and other cancers identified by conventional imaging methods. METHODS: We evaluated 43 consecutive patients (17 males, 26 females, mean age 53 +/- 6 years) with known solitary liver metastasis. This sample consisted of 18 patients with colorectal cancer, 15 with nonsmall cell lung cancer, six with breast carcinoma, and four ovarian cancers. In addition to contrast-enhanced CT and US, all patients were studied with FDG-PET/CT before surgery. PET/CT was performed within 3 weeks of the initial diagnosis and the scans were read by two experienced radiologists/nuclear medicine specialists blinded to the clinical data. A final diagnosis was obtained at surgery in 31 patients, by fine needle biopsy in five, and long-term clinical, biochemical, and follow-up imaging in seven patients. RESULTS: In 12 out of 43 patients (28%), PET/CT resulted in restaging disease and a change in therapy. Twenty-two of 31 patients with confirmed solitary liver lesions (71%) were disease-free, eight of 31 (26%) developed a new recurrence, and one of 31 (3%) died from disease progression over a 17 +/- 6-month follow-up interval. Nine of 12 patients (75%) with multiple metastases demonstrated by FDG-PET/CT were alive with disease and three of 12 (25%) deceased due to disease progression (p < 0.01) over a 17 +/- 6-month follow-up interval. CONCLUSION: The addition of FDG-PET/CT to the routine assessment of patients with liver metastasis has a significant impact on disease staging and selection of suitable candidates for solitary liver metastasis resection and outcome.

Postoperative variation of C-reactive protein and procalcitonin in patients with gastrointestinal cancer.

BACKGROUND: Despite substantial advances in radiotherapy, chemotherapy and immunotherapy, surgical management remains the standard of care, especially in patients with no evidence of distant metastases and who are fit for surgery. It is traditionally known, however, that patients undergoing surgery for gastrointestinal malignancies suffer from a high rate of infective complications and there is little information on the behavior of C-Reactive Protein (CRP) and procalcitonin (PCT) in these patients. METHODS: The study population included 18 consecutive patients with untreated gastric (n = 6) or colorectal (n = 12) carcinoma and 18 control subjects. Blood samples were collected from cancer patients the day before surgery and on the following 1, 7, 30 postoperative days. Results of PCT and CRP were corrected for plasma volume changes. RESULTS: Pre-surgery values of CRP, but not of PCT, were significantly higher in cancer patients than in controls. Both markers in patients without postoperative infections reached peak-levels on day 1. On day seven, CRP values were still significantly increased, while those of PCT were non statistically different from pre-surgery. By receiver operating characteristic (ROC) analysis, both PCT and CRP discriminated patients with or without pneumonia on the day 7 post-surgery, but not between patients with or without surgical wound infection. CONCLUSIONS: Taken together, our findings are consistent with the hypothesis that PCT might be a more useful marker than CRP for monitoring the postoperative course and diagnose severe perioperative bacterial infections in patients undergoing surgery for gastrointestinal malignancies after the 7th postoperative day.

Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results.

OBJECTIVE: The aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis. BACKGROUND: It is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. METHODS: Literature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques. RESULTS: Seven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2-2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found. CONCLUSION: A lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.

Chemoradiotherapy followed by surgery for squamous cell carcinoma of the thoracic esophagus with clinical evidence of adjacent organ invasion.

BACKGROUND: The role of surgery for esophageal squamous cell carcinoma (SCC) with clinical evidence of adjacent organ invasion (cT4) is a debated issue. This study was aimed at analyzing our experience with chemoradiotherapy (CRT) followed by surgery as treatment for non-metastatic cT4 SCC of the thoracic esophagus. METHODS: The results of 51 patients consecutively treated at the First Department of General Surgery, University of Verona, from January 1987 to December 2004 were analyzed. RESULTS: The most frequently clinically involved structures were the trachea (43.1%), the main left bronchus (17.6%), and the thoracic aorta (15.7%). CRT was completed in all but one of the patients (98.0%) without toxicity-related deaths. After completion of induction treatment 49 patients underwent surgery (96.1%), and resection was possible in 40 patients (78.4%) but R0 surgery was rarely obtained (39.2%). Pathologic downstaging was achieved in 18 cases (35.3%) while a major response (responders) was observed in 10 patients (19.6%) and a complete response (pT0N0) in 7 (13.7%). The overall median survival time was 11.1 months with a 3-year survival rate of 8.8%. A significantly better survival (P < 0.001) was observed after a R0 resection (median: 22.3 months; 3-year survival: 25.4%; P < 0.001) and for responders (median: 33.1 months; 3-year survival: 25.7%; P = 0.019). CONCLUSIONS: Aggressive multi-modal therapy with CRT followed by surgery in cT4 SCC of the thoracic esophagus is feasible. Surgery should be limited to patients with significant response to induction treatment and a high probability of R0 resection.

Incidence and clinical predictors of Kaposi's sarcoma among 1721 Italian solid organ transplant recipients: a multicenter study.

Kaposi's sarcoma (KS) can be a complication of solid organ transplantation, but with an important incidence rate variability in different geographical areas. Here we analyzed the incidence rate, timing and clinical correlates of KS, in a cohort of Italian solid organ transplant recipients from four distinct transplantation centers. A total of 1721 renal, heart and liver transplant recipients were recruited between 1997 and 2004. KS was diagnosed in 40 patients, after a median follow up of 1 year (range 0.8-5.1). Visceral involvement was detected in 7/40 patients. Incidence rate of KS in the whole population was 2.3 cases per 1000 individuals per year. The standardized incidence rate (SIR) for KS in renal transplant recipients was 149.9 (95% CI 103.0-212.0), with the excess risk greater among women (SIR 316.0) than among men (SIR 133.6). In a Cox proportional hazard regression model, age at transplantation equal or older than 30 years and only combined immunosuppressive therapy with mycophenolate mofetil + cyclosporine + prednisolone were independently associated with KS. Italian organ transplant recipients have an increased risk (about 100 times greater) for KS compared to the general population, especially during the first two years after transplantation. Age older than 30 years at transplantation and a more aggressive immunosuppressive regimen were both independent risk factors for the disease.

Intra-thoracic desmoid tumour in a patient with a previous aortocoronary bypass.

BACKGROUND: Intra-thoracic desmoid tumours with mediastinal invasion are very rare. Although rare they have to be taken into account in the differential diagnosis of a thoracic mass and therapeutic options have to be weighted since surgical treatment may require wide excision. CASE PRESENTATION: A 48-year-old male diabetic, dyslipidaemic, former heavy smoker with psychiatric illness was operated by sternotomy for a triple aorto-coronary bypass 4 years before, presented with complains of recent onset such as constant and oppressive chest pain. At surgery a mass extending from the aortic arch into the entire anterior mediastinum and to most of the right pleural cavity was found. The mass was separated from sternal periosteum and vessels of aorto-coronary by pass were isolated starting from the aortic arch up to the pericardium. The histological examination revealed aggressive fibromatosis. CONCLUSION: Although technically demanding, radical surgical excision is actually the most indicated therapeutic approach for intra-thoracic desmoid tumours.

Induction chemoradiotherapy for squamous cell carcinoma of the thoracic esophagus: impact of increased dosage on long-term results.

BACKGROUND: This study analyzed the impact on long-term results of an increase in the dosage of an induction chemoradiotherapy protocol for squamous cell carcinoma (SCC) of the thoracic esophagus. METHODS: Two groups were considered among 177 patients who underwent preoperative chemoradiotherapy for SCC of the thoracic esophagus. Group A includes 111 patients (from 1987 to 1995) who were submitted to cisplatin and 5-fluorouracil (two cycles) and radiotherapy (3,000 cGy). Group B includes 66 patients (from 1995 to 2002) in which the doses were raised both in terms of chemotherapy (three cycles) and radiotherapy (5,000 cGy). RESULTS: The induction treatment was completed in most of the patients (92.1%) with an acceptable treatment-related mortality (2.6%). Surgery was accomplished in 148 patients; 78.4% and 92.4% in groups A and B, respectively (p = 0.015). The postoperative in-hospital mortality was 8.8%. Tumor resection was possible in 91.8% with a better R0-resection rate for group B (83.9%; p = 0.004). Responders represented 34.9% of the patients with 20.1% of "complete" responses (29.5% in group B; p = 0.018). The overall 5-year survival rate was improved in group B (30.2%; p = 0.017), and when survival analysis was restricted to responders (70.1%; p = 0.027). CONCLUSIONS: No differences in feasibility and complication rate were observed during the two study periods. A higher rate of R0-resections was achieved in group B. The increased dosage led to an increased rate of complete responses and to an improved overall 5-year survival.

Transhepatic fibrinolysis of mesenteric and portal vein thrombosis in a patient with ulcerative colitis: a case report.

AIM: To present a case of acute mesenteric and portal vein thrombosis treated with thrombolytic therapy in a patient with ulcerative colitis in acute phase and to review the literature on thrombolytic therapy of mesenteric-portal system. Treatment of acute portal vein thrombosis has ranged from conservative treatment with thrombolysis and anticoagulation therapy to surgical treatment with thrombectomy and/or intestinal resection. METHODS: We treated our patient with intraportal infusion of plasminogen activator and then heparin through a percutaneous transhepatic catheter. RESULTS: Thrombus resolved despite premature interruption of the thrombolytic treatment for neurological complications, which subsequently resolved. CONCLUSION: Conservative management with plasminogen activator, could be considered as a good treatment for patients with acute porto-mesenteric thrombosis.

Surgical resection versus percutaneous radiofrequency ablation in the treatment of hepatocellular carcinoma on cirrhotic liver.

OBJECTIVE: We sought to compare the experience of 2 different surgical units in the treatment of hepatocellular carcinoma (HCC) on cirrhosis with resection or percutaneous radiofrequency ablation (RFA), respectively. SUMMARY BACKGROUND DATA: When allowed by the hepatic functional reserve, surgery is the therapy for HCC on cirrhosis; alternative treatments are proposed because of the high tumor recurrence rate after resection. RFA is being widely adopted to treat HCC. METHODS: Over a 4-year period, 79 cirrhotics with HCC underwent resection in 1 surgical unit (group A) and another 79 had RFA at a different unit (group B). Patient selection, operative mortality, hospital stay, and 1- and 3-year overall and disease-free survival were analyzed. RESULTS: Group A (surgery): mean follow-up was 28.9 +/- 17.9 months; operative mortality was 3.8%, mean hospital stay 9 days; 1- and 3-year survival were, respectively, 83 and 65%. One- and 3-year disease-free survival were 79 and 50%. Group B (RFA): mean follow-up was 15.6 +/- 11.7 months. Mean hospital stay was 1 day (range 1-8). One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free survival were 60 and 20%. Overall and disease-free survival were significantly higher in group A (P = 0.002 and 0.001). The advantage of surgery was more evident for Child-Pugh class A patients and for single tumors of more than 3 cm in diameter. Results were similar in 2 groups for Child-Pugh class B patients CONCLUSIONS: RFA has still to be confirmed as an alternative to surgery for potentially-resectable HCCs.

Radiofrequency ablation of hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: Radiofrequency ablation is useful for local destruction of primary and secondary hepatic tumors. However there is little information about long-term outcome for patients with hepatocellular carcinoma and cirrhosis. The aims of this study included the analysis of efficacy in local control of tumors, patterns of recurrence and survival rate related to severity of cirrhosis and tumor features. METHODOLOGY: From January 1998 to January 2001 we ablated 65 hepatocellular carcinomas in 53 patients with cirrhosis. Cirrhosis was related to HCV, HBV and alcohol intake in 32, 4 and 17 patients, respectively. According to Child-Pugh classification 24 and 29 patients belong to A and B class, respectively. Patients in Child-Pugh C class were excluded from the study. The mean diameter of lesions was 4 cm (range: 1-7 cm). In all cases radiofrequency ablation was performed with the percutaneous approach under ultrasound guidance. Treatment efficacy was estimated with dual phase computed tomography and alpha-fetoprotein dosage. RESULTS: Complete necrosis rate after first treatment was 90.9, 74.4 and 36.4% in hepatocellular carcinoma smaller than 3 cm, between 3 and 5 cm and larger than 5 cm, respectively (p = 0.01). After multiple treatment complete necrosis was achieved in 100, 93 and 63.6% (p = 0.01). The mean number of treatments was 1.5 (range: 1-4) per patients. Four lesions of 58 (6.8%) developed local recurrence during a mean follow-up of 18 months. No local recurrence was observed in tumors smaller than 4 cm. New tumors were observed in 15 patients (28.3%). There were no treatment-related deaths and 11 patients (20.7%) suffered minor complications. The survival rate of patients after treatment was 87, 63 and 45% at 12, 24 and 36 months, respectively. Survival was significantly related to Child-Pugh class (p = 0.01). CONCLUSIONS: Radiofrequency ablation is a safe and effective treatment of hepatocellular carcinoma smaller than 5 cm with complete necrosis in most lesions. No local recurrences were observed in lesions smaller than 4 cm. After 3 years survival was 83% in Child-Pugh A cirrhotic patients and 31% in Child-Pugh B patients.

Different patterns of recurrence in gastric cancer depending on Lauren's histological type: longitudinal study.

The aim of this multicenter longitudinal study was to evaluate the pattern of recurrence in patients submitted to potentially curative surgery for intestinal-type and diffuse-type gastric cancer. The study included 412 patients surgically treated at three Italian surgical departments, subdivided into 273 intestinal-type cases (group A) and 139 diffuse-type cases (group B). Recurrence of disease was found in 41% of group A cases and 65% of group B cases (p < 0.0001). The incidence of locoregional, hematogenous, and peritoneal recurrence was 20%, 19%, and 9% in group A, and 27%, 16%, and 34% in group B, respectively; the difference between the two groups was statistically significant for peritoneal recurrence (p < 0.0001). Multivariate analysis identified as prognostic variables lymph node status, depth of invasion, extent of lymphadenectomy, advanced age, and male gender in group A; depth of invasion, extent of lymphadenectomy, tumor size, and lymph node status, in group B. Whereas in group A the incidence of peritoneal recurrence was limited in all subgroups examined, in group B very high rates were observed in cases with infiltration of the serosa, involvement of second-level lymph nodes, or large tumor size. The notable difference in the risk of peritoneal recurrence between the intestinal and diffuse types should be taken into consideration in the therapeutic approach to gastric cancer.

Results of surgical treatment of adenocarcinoma of the gastric cardia.

BACKGROUND: Comparison among different studies regarding adenocarcinoma of the cardia has been difficult since the Siewert classification was introduced. This study analyzed the experience of a single institution in the treatment of gastric cardia cancer with the aim of assessing principal prognostic factors and long-term outcome. METHODS: The results of 96 patients who underwent resection with curative intent for gastric cardia cancer at the First Division of General Surgery, University of Verona, from January 1988 to February 2000, were analyzed statistically with special reference to Siewert type. RESULTS: Despite a high number of curative resections (85.4%), the 5-year survival rate was poor (24%) for all Siewert types (p = 0.8), and for early tumors (51%) also. Chance of cure was limited to pN0 and pN1 patients. Multivariate analysis showed that microscopic or macroscopic residual tumor and pN-positive categories had a significantly higher risk of death (risk ratio, 2.18 and 2.68, respectively) and the pN2 and pN3 category had the most negative prognostic factor (risk ratio, 7.6). CONCLUSIONS: The long-term prognosis for gastric cardia cancer remains poor and is independent of Siewert type, with cure limited to pN0 and pN1 patients.

Treatment of gallstone pancreatitis: six-year experience in a single center.

Acute pancreatitis (AP) is a complicated disease in 20% to 25% of cases and carries a mortality of 8% to 15%. Etiologically, the most frequent form is acute biliary pancreatitis. Treatment of such an entity is still controversial, but minimally invasive techniques undoubtedly play an important role. We retrospectively analyze our cases of AP observed from January 1992 to May 1998. Etiology was biliary in 95/125 (76%) cases. In 90 cases we evaluated the patient within a few hours of the onset of symptoms. According to the Ranson criteria, we observed a mild form in 74/90 (82.2%) cases and a severe form in 16/90 (17.8%) cases. Our standard policy was to perform urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy followed by elective laparoscopic cholecystectomy. In particular clinical settings, other modalities of treatment were employed, such as percutaneous cholecystostomy and percutaneous drainage of fluid collections. Successful ERCP was performed in 86/90 cases (95.5%). The procedure was performed in an emergency setting (within 48 hours) in 62/90 cases (68.9%). Whenever the patient was a candidate for surgery, cholecystectomy was performed, laparoscopically in 67/90 cases (74.4%) and via laparotomy in 7/90 cases (7.8%). In only two cases was pancreatic necrosectomy necessary. Globally, we observed a low procedure-related morbidity (6.7%) and no mortality. In the setting of acute biliary pancreatitis, regardless of the severity of the attack, an urgent ERCP + endoscopic sphincterotomy followed by laparoscopic cholecystectomy is safe and could enable successful management of the patient. Associated morbidity and mortality were low. In addition, when indicated, it is possible to treat a great number of concomitant complications with percutaneous ultrasound-guided drainage.