Extension of lymph node dissection in the surgical treatment of esophageal and gastroesophageal junction cancer: seven questions and answers.

The role of two- or three-field nodal dissection in the surgical treatment of esophageal and gastroesophageal junction cancer in the minimally invasive era is still controversial. This review aims to clarify the extension of nodal dissection in esophageal and gastroesophageal junctional cancer. A basic evidence-based analysis was designed, and seven research questions were formulated and answered with a narrative review. Reports with little or no data, single cases, small series and review articles were not included. Three-field lymph node dissection improves staging accuracy, enhances locoregional disease control and might improve survival in the group of patients with cervical and upper mediastinal metastatic lymph nodal involvement from middle and proximal-third esophageal cancer.

Clinical outcomes of patients with complicated post-operative course after gastrectomy for cancer: a GIRCG study using the GASTRODATA registry.

Gastrectomy for gastric cancer is still performed in Western countries with high morbidity and mortality. Post-operative complications are frequent, and effective diagnosis and treatment of complications is crucial to lower the mortality rates. In 2015, a project was launched by the EGCA with the aim of building an agreement on list and definitions of post-operative complications specific for gastrectomy. In 2018, the platform www.gastrodata.org was launched for collecting cases by utilizing this new complication list. In the present paper, the Italian Research Group for Gastric Cancer endorsed a collection of complicated cases in the period 2015-2019, with the aim of investigating the clinical pictures, diagnostic modalities, and treatment approaches, as well as outcome measures of patients experiencing almost one post-operative complication. Fifteen centers across Italy provided 386 cases with a total of 538 complications (mean 1.4 complication/patient). The most frequent complications were non-surgical infections (gastrointestinal, pulmonary, and urinary) and anastomotic leaks, accounting for 29.2% and 17.3% of complicated patients, with a median Clavien-Dindo score of II and IIIB, respectively. Overall mortality of this series was 12.4%, while mortality of patients with anastomotic leak was 25.4%. The clinical presentation with systemic septic signs, the timing of diagnosis, and the hospital volume were the most relevant factors influencing outcome.

An unusual clinical presentation of colonic lipomatosis: A case report.

INTRODUCTION: Colonic lipomatosis is defined as a poorly circumscribed, non-capsulated fat accumulation in the submucosal layer of the colonic wall. Clinical presentation varies from asymptomatic to acute surgical complications. PRESENTATION OF CASE: We report the case of a 79-year old male who arrived at the Emergency Department complaining of worsening abdominal pain, fever and nausea. A CT scan revealed a periappendicular abscess extended to the ileocecal valve and also the presence of diffuse intramural fatty tissue of the ascending colon. The patient underwent surgery and a right hemicolectomy was performed. The final histological exam confirmed the diagnosis of gangrenous appendicitis with diffuse abscessualization of the ileocecal valve and the presence of submucosal lipomatosis of the ICV extending to the ascending colon. Patient was discharged at 11th-POD. DISCUSSION: Acute appendicitis can represent a complication, although rare, of colonic lipomatosis. The underlying mechanism can be explained by the obstruction of the stool discharge from the appendix caused by the thickened colonic wall due to lipomatosis. Despite the lack of established guidelines on the management of colonic lipomatosis, surgery remains the preferred treatment in case of acute complications. CONCLUSION: Acute appendicitis is a rare clinical manifestation of colonic lipomatosis. As in the case of other acute complications, such as intussesception, surgery remains the preferred therapeutic approach.

Hepatobiliary and pancreatic surgery in the elderly: Current status.

Hepato-pancreatico-biliary (HPB) surgery includes major hepatic resection and pancreatic surgery, both procedures are complex and have a potentially high complication rate. The presence of centers of excellence with a high patients volume has lowered the complication and increased the resection rate. Increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Since old patients have more co-morbidities and decreased life expectancy, the benefit of these procedures need to be critically evaluated in this group. Analysis of the literature related to this argument demonstrated that pancreatoduodenectomy can be performed safely in selected elderly patients (70 years of age or older), with morbidity and mortality rates comparable those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumor or gallbladder carcinoma. More studies are needed regarding the subgroup of very elderly patients (80 years or older). Nevertheless, those elderly patients who will benefit from surgery must be adequatelly selected.

The Role of Minimally Invasive Surgery in the Treatment of Lung Metastases.

INTRODUCTION: The ideal surgical approach for pulmonary metastasectomy remains controversial. Thoracoscopic surgery may offer advantages in quality of life outcomes, with equivalent oncologic long-term results. This study aimed to demonstrate the validity of video-assisted thoracoscopic surgery (VATS) in the treatment of lung metastases. METHODS: In all 224 patients who underwent 300 VATS metastasectomies from January 2000 to December 2013 were retrospectively reviewed. Sixty-nine patients underwent major resection (68 thoracoscopic lobectomies and one pneumonectomy) and 155 patients underwent a wedge resection/segmentectomy. Complete curative pulmonary resections were performed in 219 (97%) cases. The Kaplan-Meier method was used to estimate survival curves. Univariate and subsequent multivariate Cox model regression were performed to identify independent factors of overall survival. RESULTS: One hundred eighty-six patients developed lung metastases from epithelial tumors, 28 from sarcomas, seven from melanomas, and three from germ cell tumors. The final pathological examination revealed no cases of R1 disease. After a mean follow-up of 40 months, 118 patients (53%) had died. According to a multivariate analysis, a better prognosis was not observed for patients with a particular histological type; in addition, disease-free interval time, age, number of metastases, and type of surgery did not have any statistical influence on long-term survival. CONCLUSIONS: Thoracoscopic surgery is a safe and efficacious procedure, with a five-year overall survival that is equivalent to open surgery.

Abdominal wall desmoid tumors: A proposal for US-guided resection.

BACKGROUND: Desmoid tumors (DTs) is a benign tumor with high tendency to infiltrative evolution and recurrence. Nowadays, in abdominal localization, the standard approach is surgery with R0 condition. The need to repair post-surgical wide wall defect requires conservative technique to decrease the incidence of incisional hernia and to obtain better quality of life (QoL). METHODS: We perform an abdominal wall desmoid resection using ultrasound guide. This technique ensures to spare a wide wall area and to obtain a multilayer reconstruction minimizing postoperative risk. This approach allows good oncological results and better managing abdominal wall post-resection defect. RESULTS: We use US guided surgery to get radical approach and wall tissue spare that allows us a multilayer reconstruction minimizing post-operative complications. No recurrences were observed in one year follow up period. CONCLUSION: Our experience represents first step to consider ultrasound mediated technique usefull to optimize wall resection surgery and to minimize following complications.

Ruptured aneurysm of replaced left hepatic artery.

Hepatic artery aneurysm is an uncommon and potentially fatal form of vascular disease. We report the case of a 53-year-old man with an isolated, nontraumatic rupture of an aneurysm of a replaced left hepatic artery originating from the left gastric artery. This case is unusual because the ruptured aneurysm involved an hepatic artery with a rare vascular pattern.

[Preliminary experience with hyperthermic intraperitoneal chemo-perfusion with oxaliplatin for the treatment of peritoneal carcinomatosis due to colorectal carcinoma]. / Espenrenza preliminare di trattamento della carcinosi peritoneale da carinoma colorettale mediante chemio-ipertermia ntaperitoneale con oxaliplatino.

Peritoneal carcinomatosis is the first cause of death after surgery for abdominal cancer, with a mean survival of 7 months. In selected patients, aggressive cytoreductive therapy combined with hyperthermic intraperitoneal chemotherapy my improve medium to long-term survival. Over the period from 2004 to January 2006, 86 patients were operated on for peritoneal carcinomatosis at the Division of Surgical Oncology, Forli, Italy. Thirteen of them were submitted to hyperthermic chemotherapy. The authors present their preliminary experience with the treatment of colorectal carcinosis by 30-min hyperthermic (41.5-42 degrees C intraperitoneal perfusion with oxaliplatin (400 mg/sq.m.) and intravenous 5-FU (400 mg/sq.m.) after complete cytoreductive surgery. The average surgical time was 606 min (range: 380-765). No intraoperative complications occurred, but 4 cases of major postoperative morbidity were reported, one of which requiring surgery. One patient died 5 months postoperatively due to lung metastases. The remaining patients are alive and free from peritoneal disease.

The sentinel node biopsy in early gastric cancer: a preliminary study.

BACKGROUND AND AIMS: Sentinel node biopsy is currently used in surgery of malignant melanoma and breast cancer. The feasibility of sentinel node mapping in gastrointestinal cancers and its diagnostic sensitivity is unclear. It could be of particular value in the management of early gastric cancer in which radical D2 lymphadenectomy may be unnecessary. MATERIALS AND METHODS: From January 2004 to June 2005, ten patients with preoperative diagnosis of early gastric cancer and no nodal involvement (cT1N0) were submitted to sentinel node biopsy using the dual mapping procedure with endoscopic blue dye and 99mTc radio colloid injection. All the patients underwent standard radical gastrectomy and D2 lymphadenectomy. The resected nodes were evaluated by routine (hematoxylin-eosin) histopathological examination; the sentinel (blue or hot) nodes, in addition, were evaluated with immunohistochemistry for cytokeratin. RESULTS: The detection rate of this procedure was 100%. The preliminary results and perspectives for feasibility of sentinel node biopsy and its accuracy in predicting the nodal status in early gastric cancer are discussed.

[Considerations regarding the role of arterial embolization with an angiographic approach in the treatment of upper gastrointestinal bleeding: personal experience]. / Considerazioni sul ruolo dell'embolizzazione celiaco-mesenterica con approccio arteriografico nel trattamento delle emorragie gastrointestinali alte: esperienza personale.

Upper gastrointestinal bleeding can be produced by varicose, inflammatory-ulcerative or neoplastic lesions of the eosophageal-gastric-duodenal anatomical district. The aim of this study was to define the role of arterial embolotherapy with an angiographic approach in the treatment of these conditions, starting from our personal experience and a review of the literature. The treatment of upper gastrointestinal bleeding is based on a multimodal approach in which arterial embolotherapy has its place alongside endoscopy and surgery.