Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis.

PURPOSE: Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown. METHODS: A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables. RESULTS: Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I2= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I2= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I2= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I2= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I2= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I2= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I2= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I2= 97%). CONCLUSIONS: The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.

Advances in modelling alpha-synuclein-induced Parkinson's diseases in rodents: Virus-based models versus inoculation of exogenous preformed toxic species.

Aggregates of alpha-synuclein (αSyn) have been described in Parkinson's disease (PD) patients, and recent evidence has suggested that the most toxic αSyn species in PD are small soluble aggregates including oligomers, prefibrils, protofibrils. The physiological function of αSyn is still highly debated, with a possible role in synaptic vesicle trafficking and release at the presynaptic compartment, and in the regulation of gene expression in the nucleus. Emerging evidence indicate that most of αSyn functions are related with the crucial ability to bind biological membranes, which is associated with structural conversion from a disordered monomer to an α-helical enriched structure. Conformational properties of αSyn can be modulated by a number of factors including post-translational modifications, gene duplication and triplication-driven overexpression, single point mutations, environmental changes, which affect membrane binding and the protein propensity to aggregate in toxic species. The recognized toxic role of αSyn in PD has laid the rational for purposing of αSyn-based, neuropathologically relevant preclinical models of PD. Different approaches have led to the establishment of transgenic models, viral vector-based models, and more recently models based on the intracerebral inoculation of exogenous αSyn preformed fibrils/oligomers. Here, we overview and compare viral vector-based models of αSyn overexpression and models obtained by direct intracerebral infusion of in vitro preformed αSyn species. The advantages and pitfalls associated with these different approaches are discussed.

Activation of PPAR gamma receptors reduces levodopa-induced dyskinesias in 6-OHDA-lesioned rats.

Long-term administration of l-3,4-dihydroxyphenylalanine (levodopa), the mainstay treatment for Parkinson's disease (PD), is accompanied by fluctuations in its duration of action and motor complications (dyskinesia) that dramatically affect the quality of life of patients. Levodopa-induced dyskinesias (LID) can be modeled in rats with unilateral 6-OHDA lesions via chronic administration of levodopa, which causes increasingly severe axial, limb, and orofacial abnormal involuntary movements (AIMs) over time. In previous studies, we showed that the direct activation of CB1 cannabinoid receptors alleviated rat AIMs. Interestingly, elevation of the endocannabinoid anandamide by URB597 (URB), an inhibitor of endocannabinoid catabolism, produced an anti-dyskinetic response that was only partially mediated via CB1 receptors and required the concomitant blockade of transient receptor potential vanilloid type-1 (TRPV1) channels by capsazepine (CPZ) (Morgese et al., 2007). In this study, we showed that the stimulation of peroxisome proliferator-activated receptors (PPAR), a family of transcription factors activated by anandamide, contributes to the anti-dyskinetic effects of URB+CPZ, and that the direct activation of the PPARγ subtype by rosiglitazone (RGZ) alleviates levodopa-induced AIMs in 6-OHDA rats. AIM reduction was associated with an attenuation of levodopa-induced increase of dynorphin, zif-268, and of ERK phosphorylation in the denervated striatum. RGZ treatment did not decrease striatal levodopa and dopamine bioavailability, nor did it affect levodopa anti-parkinsonian activity. Collectively, these data indicate that PPARγ may represent a new pharmacological target for the treatment of LID.

Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair.

PURPOSE: The hypothesis of this meta-analysis was to assess whether laparoscopic approach shows real benefits over Lichtenstein technique in recurrent inguinal hernia repair. METHODS: A literature search for prospective randomized trials comparing laparoscopic and Lichtenstein procedure in recurrent inguinal hernia repair was performed. Trials were reviewed for primary outcome measures: re-recurrence, chronic inguinal pain and ischemic orchitis; and for secondary outcome measures. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for dichotomous variables. RESULTS: Seven studies comparing laparoscopic and Lichtenstein technique were considered suitable for the pooled analysis. Overall 647 patients with recurrent inguinal hernia were randomized to either laparoscopic repair (333, 51.5 %, transabdominal preperitoneal approach, TAPP and totally extraperitoneal approach, TEP) or anterior open repair (314, 48.5 %, Lichtenstein operation). Patients who underwent laparoscopic repair experienced significantly less chronic pain (9.2 % vs. 21.5 %, p = 0.003). Patients of the laparoscopic group had a significantly earlier return to normal daily activities (13.9 vs. 18.4 days, SMD = -0.68, 95 % CI = -0.94 to -0.43, p < 0.000001). Operative time was significantly longer in laparoscopic operations (62.9 vs. 54.2 min, SMD 0.46, 95 % CI 0.03, 0.89; p = 0.04). No other differences were found. CONCLUSIONS: Laparoscopy showed reduced chronic inguinal pain and an earlier return to normal daily activities but significantly longer operative time. Despite the expected advantages, the choice between laparoscopy and other techniques still depends on local expertise availability. Only dedicated centers are able to routinely offer laparoscopy for recurrent inguinal hernia repair.

Encapsulated papillary thyroid carcinoma: is it a distinctive clinical entity with low-grade malignancy?

BACKGROUND: Encapsulated papillary thyroid carcinoma (EPTC) is commonly retained as a tumor with indolent clinical courses. Herein we focused on the search for factors predicting biological behavior and influencing prognosis of EPTC in comparison with the non-encapsulated counterpart of papillary thyroid carcinoma (NEPTC). METHODS: From January 1998 to May 2009, 348 patients underwent thyroidectomy in our surgical department because of papillary thyroid carcinoma (PTC). A cross-sectional study of 52 patients with EPTC and 296 patients with NEPTC was carried out: demographic data, tumor characteristics, diagnostic results, patient management, post-operative and follow-up results were evaluated. RESULTS: EPTC patients were significantly younger than patients with NEPTC (44.5 vs 48.8 yr, p<0.04). Mean tumor size was significantly greater for EPTC than for NEPTC (2.36 vs 1.41 cm, p<0.001). Tumor multifocality, thyroid capsular invasion, and lymph node involvement at diagnosis were significantly associated with NEPTC (p=0.0001, p<0.0001, and p=0.027, respectively). Multivariate analyses showed that NEPTC classical variant were at risk for both thyroid capsular invasion and nodal involvement (odds ratio 6.870 and 9.514, respectively) while EPTC were not. Nodal metastasis at diagnosis was the only factor influencing recurrence. CONCLUSIONS: The majority of EPTC had risk-free clinical courses as a result of their low risk of locoregional spread. However, definitive recommendations need a longer follow-up and a comparison with a lesser treated group of patients belonging to the same category of risk at diagnosis.

Rosiglitazone decreases peroxisome proliferator receptor-γ levels in microglia and inhibits TNF-α production: new evidences on neuroprotection in a progressive Parkinson's disease model.

Thiazolidinedione (TZD) class of peroxisome proliferator receptor gamma (PPAR-γ) agonists display neuroprotective effects in experimental Parkinson's disease (PD) models. Neurons and microglia express PPAR-γ, therefore both of them are potential targets for neuroprotection, although the role of each cell type is not clear. Moreover, receptor-dependent as well as receptor-independent mechanisms have been involved. This study further investigated mechanisms of TZD-mediated neuroprotection in PD. We investigated the rosiglitazone effect in the progressive MPTP/probenecid (MPTPp) model of PD. C57BL/6J mice received MPTP (25 mg/kg) plus probenecid (100 mg/kg) twice per week for 5 weeks. Rosiglitazone (10 mg/kg) was given daily until sacrifice, starting on the fourth week of MPTPp treatment, in presence of an ongoing neurodegeneration with microgliosis. Changes in PPAR-γ levels were measured by immunofluorescence and confocal microscopy in tyrosine hydroxylase (TH)-positive neurons and CD11b-positive microglia of the substantia nigra pars compacta (SNc). Chronic MPTPp treatment induced a PPAR-γ overexpression in both TH-positive neurons and microglia (139.9% and 121.7% over vehicle, respectively). Rosiglitazone administration to MPTPp-treated mice, reverted PPAR-γ overexpression in microglia without affecting TH-positive neurons. Thereafter, changes in CD11b and tumor necrosis factor α (TNF-α) immunoreactivity in microglia were evaluated in the SNc. MPTPp progressively increased CD11b immunoreactivity, conferring to microglia a highly activated morphology. Moreover, TNF-α levels were increased (457.38% over vehicle) after MPTPp. Rosiglitazone administration counteracted the increase in CD11b immunoreactivity caused by MPTPp. Moreover, rosiglitazone reverted TNF-α expression to control levels. Nigrostriatal degeneration was assessed by high pressure liquid chromatography (HPLC) measurement of striatal dopamine, and counting of TH-positive neurons in the SNc. MPTPp treatment caused a severe decline of striatal dopamine and a partial degeneration of the SNc. Rosiglitazone arrested the degenerative process in both areas. Results suggest that PPAR-γ expression in microglia and TNF-α production by these cells are crucial changes by which rosiglitazone exerts neuroprotection in PD.

Triiodothyronine stimulates hepatocyte proliferation in two models of impaired liver regeneration.

OBJECTIVES: Liver regeneration is attenuated in old age and is substantially slower after 90% than after 70% partial hepatectomy (PH). We have previously demonstrated that the proliferative response to a primary mitogen is intact in aged mice, indicating that impaired liver regeneration is not due to loss of proliferative capacity. Here, we have investigated whether mitogenic effects of triiodothyronine (T3) could reverse the impaired regeneration of ageing or 90% hepatectomy, in the rat. MATERIALS AND METHODS: T3 (20 microg/100 g body weight) was administered to 14-month-old rats subjected to 70% PH or to young rats subjected to 90% PH. Cell-proliferative capacity was determined by bromodeoxyuridine incorporation and microscopy and changes of cell cycle-related proteins were analysed by Western blot analysis. RESULTS: Treatment of old intact rats with T3 increased cyclin D(1) expression that was followed by an enhanced proliferative response, the labelling index (LI), being 7.8% versus 1.3% of controls. T3 given before 70% PH stimulated regenerative response (LI was 10.8% versus 2.28%), and expression of cyclin D(1) and proliferating cell nuclear antigen (PCNA) 24 h after PH. Pre-treatment with T3 also improved the regenerative response of the liver after 90% hepatectomy (LI was 27.9% versus 14.2%). CONCLUSIONS: These findings show in principle that mitogen-induced hyperplasia could be applied to human therapy in patients with reduced regenerative capacity or massive loss of hepatocytes.

Two-phase anaerobic digestion within a solid waste/wastewater integrated management system.

A two-phase, wet anaerobic digestion process was tested at laboratory scale using mechanically pre-treated municipal solid waste (MSW) as the substrate. The proposed process scheme differs from others due to the integration of the MSW and wastewater treatment cycles, which makes it possible to avoid the recirculation of process effluent. The results obtained show that the supplying of facultative biomass, drawn from the wastewater aeration tank, to the solid waste acidogenic reactor allows an improvement of the performance of the first phase of the process which is positively reflected on the second one. The proposed process performed successfully, adopting mesophilic conditions and a relatively short hydraulic retention time in the methanogenic reactor, as well as high values of organic loading rate. Significant VS removal efficiency and biogas production were achieved. Moreover, the methanogenic reactor quickly reached optimal conditions for a stable methanogenic phase. Studies conducted elsewhere also confirm the feasibility of integrating the treatment of the organic fraction of MSW with that of wastewater.

Modulation of Delta(9)-THC-induced increase of cortical and hippocampal acetylcholine release by micro opioid and D(1) dopamine receptors.

The administration of Delta(9)-tetrahydrocannabinol (Delta(9)-THC) and synthetic cannabinoids stimulates acetylcholine (ACh) release in the rat prefrontal cortex (PFCx) and hippocampus as estimated by brain microdialysis. The present study was aimed at assessing whether the ability of Delta(9)-THC to stimulate ACh release is dependent upon opioid and dopamine (DA) receptors. Administration of the micro opioid receptor antagonists naloxone and naltrexone prevented the Delta(9)-THC-induced release of ACh in the PFCx and hippocampus. Similarly, bilateral infusion in the ventral tegmental area (VTA), 24h before Delta(9)-THC, of the pseudo-irreversible micro(1) antagonist naloxonazine completely prevented the increase of ACh release by Delta(9)-THC. Pre-treatment with the D(1) receptor antagonist SCH 39,166 reduced Delta(9)-THC-induced ACh release both in the PFCx and in the hippocampus. Since Delta(9)-THC has been shown to increase DA release in the nucleus accumbens (NAc) shell via a micro(1)-opioid receptor mediated mechanism located in the VTA (Tanda, G., Pontieri, F.E., Di Chiara, G., 1997. Cannabinoid and heroin activation of mesolimbic dopamine transmission by a common micro(1) opioid receptor mechanism. Science 276, 2048-2050.), we hypothesize that Delta(9)-THC-induced stimulation of ACh release in the PFCx and hippocampus is related to stimulation of endogenous opioids release in the VTA with secondary activation of DA neurons projecting to the NAc shell.

Hypocalcemia following total thyroidectomy: early factors predicting long-term outcome.

Hypocalcemia following total thyroidectomy (TT) must be considered permanent in patients requiring calcium replacement after one year. The aim of this study was to identify early risk factors predicting long-term outcome of postoperative hypocalcemia. Among 453 patients who underwent TT from January 1998 to May 2003, a cross-sectional study between 44 patients with transient hypocalcemia (9.7%) and 3 patients with permanent hypocalcemia (0.7%) was carried out. Both low serum calcium level (< 8 mg/dl) and high serum phosphorus level (> 4.5 mg/dl), measured on postoperative day 7, were predictive for outcome. Central neck lymph node dissection, performed for thyroid carcinoma, also correlated with outcome. Serum phosphorus level > 4.5 mg/dl on postoperative day 7 resulted the only independent factor predicting permanent hypoparathyroidism. Therefore indication for central dissection would be very strict. When serum phosphorus level is unfavorable a correct replacement therapy is mandatory to prevent the consequences of permanent hypocalcemia.

GIST: a clinical dilemma.

The authors report a clinical case of malignant gastric and duodenojejunal GIST, in which the only surgical treatment seems to be definitive. In a 69-year-old female, a surgical resection of the gastric and duodenojejunal tumor was performed. Histological analysis showed two spindle cells stromal tumors with mitotic rate >20/10 HPF and its uncommitted origin was demonstrated. Despite the high malignancy degree, the patient refused chemotherapy treatment and there were no local recurrence nor metastasis at a follow-up of 8 years. For this reason and because of the uncertain behavior of histologically benign GIST, the authors propose a lifelong follow-up of all patients managed with potentially curative surgical resection.

One-stage treatment in emergency setting for obstructing colorectal cancer.

The aim of this study was to evaluate the indications for one-stage treatment of obstructing colorectal cancer. From January 1998 to December 2003, 19 patients were operated on at our department for obstructing colorectal cancer. Thirteen patients underwent one-stage operation with immediate anastomosis without diversion, while 6 patients were managed palliatively. We performed resection and anastomosis following intraoperative irrigation in obstructing sigmoid cancer without colonic wall lesions, while subtotal colectomy was carried out in case of massively distended colon with ischemic lesions. Colostomy was indicated in 6 high-risk patients with unresectable lesions. In case of obstructing left colorectal cancer, an experienced surgeon can perform one-stage resection and anastomosis on good general status patients, conversely defunctioning colostomy may be ideal for surgeons with little experience in colorectal surgery and in very poor prognosis patients.

Toxocara canis in experimentally infected pigs: migratory pattern and tissue lesions.

Fifteen Yorkshire female pigs were inoculated with 100,000 infective T. canis eggs. Three animals were used as uninfected controls. Groups of three infected pigs were euthanized by accepted methods on days 7, 14, 21, 28 and 126 p.i., respectively. Larvae were recovered from all animals included in each group slaughtered on days 7 and 14 p.i.; on day 21 p.i. from two pigs, on day 28 p.i. from one, and no larvae were found on day 126 p.i. Differences in the mean number of larvae per gram in lymph nodes, liver and lungs between slaughter days, were significant for livers on day 7 p.i. and for lungs on day 14 p.i. (P < 0.10). The decrease over time was significant in all the organs that previously had larvae. Larvae were not found in the other organs and tissues analysed. Macroscopical lesions were found in the liver, lungs and lymph nodes on days 7, 14, 21, and 28 p.i. The entire surface of the liver was covered with small white spots on day 7 p.i., on days 14 and 21 p.i. the spots were distinctly nodular and, in some places, individual lesions were confluent. Lesions had apparently started to heal on days 28 and 126 p.i. appearance was normal. Lymph nodes were enlarged and oedematous during the first 4 weeks and the lungs had small areas of consolidation visible all over the surface, but by day 126 p.i., no visible lesions could be seen. Microscopical lesions were observed in the liver on day 7 p.i., with a largely periportal hepatitis. Numerous eosinophils and lymphocytes were present. The typical granulomatous reaction was observed on days 14 and 21 p.i. with a central necrotic core and a narrow region of fibroblastic tissue. By day 28 p.i. lesions had almost disappeared and the number of eosinophils was fewer. There were fewer leukocytes and the fibrous tissue had disappeared from the liver on day 126 p.i. For the first 3 weeks, pictures of the lymph nodes and the lungs were characterised by the formation of a granuloma. In the center of the granuloma larvae were observed. The majority of the lesions had healed by day 126 p.i.

[Predictive factors for malignancy in Hürthle-cell thyroid neoplasia. Effect of surgical treatment]. / Fattori predittivi di malignità nelle neoplasie tiroidee a cellule di Hürthle. Influenza sul trattamento chirurgico.

The aim of this study has been to evaluate factors predicting malignancy in patients with Hürthle cell neoplasms. Medical records from 36 patients who underwent thyroidectomy for Hürthle cell neoplasms between January 1998 and December 2002 were analyzed. Of the 36 patients, 19 had carcinomas and 17 had adenomas, resulting in a 52.7% prevalence of malignancy. Both fine-needle aspiration and intraoperative frozen section had low sensitivities in cancer detection (22.2% and 33.3% respectively). Hürthle cell carcinomas were significantly larger than adenomas (30.3 mm +/- 3.9 vs 17.6 mm +/- 2.3, P = 0.012), however 42% of carcinomas had a diameter between 10 and 20 mm. Size of Hürthle cell tumors is predictive of malignancy, but it is not the only factor to make surgical decision effective. Because of these uncertainties, authors believe that total thyroidectomy is the treatment of choice of all Hürthle cell neoplasms.

Bile leak from the accessory biliary duct following laparascopic cholecystectomy.

Anatomists and surgeons have described the presence of accessory biliary ducts between the liver and gallbladder. Bile leakage from accessory duct following laparoscopic cholecystectomy (LC) is an unusual post-operative complication. Aim of the study was to assess its incidence, the intraoperative methods helpful for notice the anatomical anomaly and the impact of endoscopic procedure as a suitable treatment. From January 1997 to September 2002, 185 patients underwent LC for symptomatic cholelithiasis in our surgical department. Post-operative bile leakage from accessory biliary duct occurred in two patients (1%): one case from the liver bed of gallbladder (duct of Luschka) and one case from an aberrant cholecystohepatic duct entering Hartmann's pouch. One patient underwent open celiotomy because of unavailability of endoscopic retrograde cholangiopancreatography. The other patient was successfully treated by endoscopic sphincterotomy and nasobiliary tube placement. By careful dissection, accessory ducts were noticed and clipped in three other patients with overall incidence of 2.7%. Meticulous laparoscopic technique aimed to careful recognize all structures during LC is the main policy to contain biliary injury within its nadir incidence. Depending of availability, endoscopic sphincterotomy and nasobiliary drainage allow diagnosis and treatment of bile leakage, preserving the effectiveness of laparoscopic procedure.

Behavioural sensitization after repeated exposure to Delta 9-tetrahydrocannabinol and cross-sensitization with morphine.

RATIONALE: Repeated exposure to several drugs of abuse has been reported to induce behavioural sensitization. So far no evidence has been provided that such a phenomenon also applies to cannabinoids. OBJECTIVES: In this study we investigated if repeated exposure to Delta(9)-tetrahydrocannabinol (Delta(9)-THC) induces behavioural sensitization. In addition we tested the possibility of cross-sensitization between Delta(9)-THC and morphine. METHODS: Male Sprague-Dawley rats were administered for 3 days, twice daily, with increasing doses of Delta(9)-tetrahydrocannabinol (2, 4 and 8 mg/kg i.p.) or increasing doses of morphine (10, 20 and 40 mg/kg s.c.) or vehicle. After a washout of 14 days the animals were challenged with Delta(9)-THC (75 and 150 microg/kg i.v.), with a synthetic cannabinoid agonist WIN55212-2 (75 and 150 microg/kg i.v.) or with morphine (0.5 mg/kg i.v.), through a catheter inserted into the left femoral vein 24 h before, and the behaviour recorded. RESULTS: Rats previously administered with Delta(9)-THC showed a greater behavioural activation compared to controls in response to challenge with Delta(9)-THC (150 microg/kg i.v.) and to challenge with morphine (0.5 mg/kg i.v.). Similar to that observed after repeated opiates, this behavioural sensitization was characterized by stereotyped activity. Animals administered with a schedule of morphine that induces behavioural sensitization to morphine also showed a behavioural sensitization to challenge with cannabinoids (Delta(9)-HC and WIN55212-2, 75 and 150 microg/kg i.v.). The effect of the challenge with Delta(9)-THC was prevented by the administration of the CB1 antagonist SR141716A (1 mg/kg i.p.), 40 min beforehand. CONCLUSIONS: The results of the present study demonstrate that repeated exposure to Delta(9)-THC induces behavioural sensitization not only to cannabinoids but also to opiates. This cross-sensitization was symmetrical since rats behaviourally sensitized to morphine were also sensitized to cannabinoids. These observations further support the evidence of an interaction between the opioid and the cannabinoid system and might provide a neurobiological basis for a relationship between cannabis use and opiate abuse.

Uncommitted gastrointestinal stromal tumour. Case report.

Gastrointestinal Stromal Tumours (GIST) are mesenchymal tumours with uncertain prognosis. Malignant variety represents about 2.0% of malignant gastroenteric tumours. The Authors report a clinical case of malignant gastric and duodenojejunal GIST, in which the only surgical treatment seems to be definitive. R. S., a 69-year-old female, was admitted for asthenia and fever in January 1997. Endoscopic exploration, ultrasonography and CT-scan of the abdomen demonstrated an exophytic tumour in the greater gastric curvature and one tumour of 5.5 cm of diameter in the Treitz's angle. We performed a resection of the gastric tumour and the duodenojejunal angle. Postoperative course was uneventful and the patient was discharged after 14 postoperative hospital days. Histological analysis showed two spindle cells stromal tumours with mitotic rate > 20/10 HPF. The immunohistochemistry demonstrated the uncommitted origin of tumour cells. The patient refused the chemotherapy treatment. There was no local recurrence or metastasis at a follow up of 47 months, in spite the high malignancy degree. For this reason and because of the uncertain behaviour of benign GIST, the authors propose a lifelong follow up of the patients managed with potentially curative surgical resection.