Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis.

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

Multidimensional Prognostic Index (MPI) score has the major impact on outcome prediction in elderly surgical patients with colorectal cancer: The FRAGIS study.

BACKGROUND: This study aims (I) to evaluate whether the Multidimensional Prognostic Index (MPI) score is associated with postoperative outcomes and (II) to develop a prognostic model for individual complication-risk prediction following colorectal cancer (CRC) surgery. METHOD: This is a prospective multicentric cohort study. Consecutive ≥75-year-old candidates for elective CRC surgery were enrolled from October 2017 to August 2019. Patients underwent standardized preoperative geriatric assessment including the MPI. Patients with MPI score > 0.33 were classified as frail. Logistic regression models were employed to evaluate variables associated with major postoperative complications and mortality, using 10-fold cross-validated LASSO (least absolute shrinkage and selection operator) for model selection. RESULTS: In all, 104 patients were included, 34 (33%) had MPI score > 0.33. Major postoperative complications occurred in 52% of frail versus 16% of fit (MPI score ≤ 0.33) patients (p < .01). Both 30-day (9% vs. 0%; p = .033) and 90-day mortality (18% vs. 1%; p < .01) were higher among frail patients. In multivariate analysis, MPI score was associated with adverse outcomes. A final postoperative complication predictive model was created, including MPI score, gait-speed test, ASA (American Society of Anesthesiology) score, surgical approach, and stoma creation. CONCLUSION: MPI score is strongly associated with postoperative major complications in CRC elderly patients and it is a primary component of an individual prediction model.

Long-Term Outcomes of Immunohistochemically Defined Subtypes of Breast Cancer Less Than or Equal to 2 cm After Breast-Conserving Surgery.

BACKGROUND: Molecular subtype predicts the prognosis of early-stage breast cancer patients. We assessed the long-term outcomes of breast cancer ≤2 cm treated with breast-conserving surgery (BCS) and stratified according to an immunohistochemically (IHC)-based subtype definition. METHODS: This retrospective study was conducted from a prospectively collected database. Included patients had pT1, any N, M0 breast cancer after BCS (without anti-HER2 therapy) and available information on estrogen receptor (ER), progesterone receptor (PR), HER2 status, Ki-67 index. Five IHC-defined subtypes were identified: luminal A-like (ER and/or PR-positive/HER2-negative/Ki-67 < 20%), luminal B-like/HER2-negative (ER and/or PR-positive/HER2-negative/Ki-67 ≥ 20%), luminal B-like/HER2-positive (ER and/or PR-positive/HER2-positive/any Ki-67 value), HER2-positive/nonluminal (ER and PR-negative/HER2-positive), and triple-negative (ER and PR-negative/HER2-negative). RESULTS: We analyzed 184 (65%) luminal A-like, 57 (20%) luminal B-like/HER2-negative, 17 (6%) luminal B-like/HER2-positive, 6 (2%) HER2-positive/nonluminal, and 18 (7%) triple-negative patients. Median follow-up was 112 (interquartile range 94-125) mo. The cumulative 5- and 10-y local recurrence (LR) rates were 1.5% and 4%, respectively. The cumulative 5- and 10-y distant recurrence (DR) rates were 3% and 8%, respectively. The Cox regression revealed that HER2-positive/nonluminal subtypes had the highest risk of LR (P = 0.0025). The luminal B-like/HER2-positive subtypes had the highest risk of DR (P = 0.0019). HER2 positivity carried a higher risk of DR in women with luminal breast cancer who completed 5 y of adjuvant hormonal therapy (P = 0.02). CONCLUSIONS: The IHC-defined subtype impacts on the prognosis of breast cancer ≤2 cm after BCS, determining significant differences in LR and DR rates. In the pre-"anti-HER2 therapy" era, patients with HER2-positive/nonluminal or luminal B-like/HER2-positive subtype had worse long-term outcomes than those with luminal A-like subtype.

Additional Cavity Shaving at the Time of Breast-Conserving Surgery Enhances Accuracy of Margin Status Examination.

PURPOSE: We addressed the impact of separate cavity margin excision (shaving) during breast-conserving surgery (BCS) for breast cancer on specimen volume, tumor margin clearance, re-excision rate, local recurrence and survival. METHODS: A retrospective case-matched study was performed on 298 women with stage 0-III breast cancer; 179 patients received shaving (shaving + lumpectomy group; SLG) and 119 patients did not (lumpectomy group; LG). RESULTS: The two groups had similar baseline characteristics. The median volume of surgical specimen was 131.9 cc in the SLG versus 134.8 cc in the LG (p = 0.81), and surgical margins were tumor-free in 90.7 % of cases in the LG versus 92.7 % in the SLG (87.1 % before shaving) (p = 0.69). The re-excision rate was 14.3 % in the LG versus 10.6 % in the SLG (p = 0.44). In the SLG, shaving spared 10 (5.6 %) patients from reoperation (positive lumpectomy margins but tumor-free shaving margins) (p = 0.11), and only 2/19 (10.5 %) patients in the SLG had tumor-free response at histological examination of re-excised margins compared with 10/17 (58.8 %) cases in the LG (p = 0.004). Tumor in shavings was found in 44/156 (28.2 %) patients having tumor-free lumpectomy margins. At multivariate analysis, distance of tumor from lumpectomy margins, tumor multifocality, receptor status, and tumor size were related to tumor persistence in shavings. Median follow-up was 27 months (range 23-35), and two patients had tumor relapse in the SLG versus none in the LG (p = 0.16). Overall survival was 100 % in both groups. CONCLUSIONS: Shaving does not significantly decrease the re-excision rate but provides wider clear margins in most procedures. It ensures more accurate margin examination and decreases false-positive margin rate, without any increase in removed breast-tissue volume.

Perivascular epithelioid cell tumor located retroperitoneally with pulmonary lymphangioleiomyomatosis: report of a case.

Perivascular epithelioid cell neoplasms, also known as "PEComas", are unusual mesenchymal tumors, exhibiting perivascular epithelioid cell differentiation and characterized by a mixed myogenic and melanocytic phenotype. "PEComas not otherwise specified" (PEComas-NOS) are especially rare; consequently, there are no published large series, but only case reports. These tumors are rarely located retroperitoneally, with only about 15 such cases reported. We report a case of pulmonary diffuse lymphangioleiomyomatosis with large retroperitoneal PEComa-NOS in a 66-year-old woman. Treatment consisted only of tumor resection, without additional adjuvant therapy. We emphasize the importance of correct immunohistochemistry diagnosis, initiation of recommended treatment, and surveillance of this unique family of tumors.

Impact of obesity on early surgical and oncologic outcomes after total gastrectomy with "over-D1" lymphadenectomy for gastric cancer.

INTRODUCTION: The purpose of the present study was to assess the impact of body mass index (BMI) on perioperative and pathologic outcomes after total gastrectomy with "over-D1" dissection for gastric cancer. METHODS: Data on 161 patients undergoing total gastrectomy between 2005 and 2011 were reviewed. Patients were grouped into three categories by BMI: BMI < 25 kg/m(2) (63 normal-weight patients; 39.1 %), BMI ≥ 25-<30 kg/m(2) (73 overweight patients; 45.3 %), and BMI ≥ 30 kg/m(2) (25 obese patients; 15.6 %) and matched for the analysis of perioperative and cancer-related outcomes. RESULTS: Operative time was longer for obese patients. Medical (mainly pulmonary) and surgical (mainly bleeding and wound infection) complications occurred more frequently in overweight/obese subjects. However, they were mostly managed conservatively (grade I-II in the Clavien-Dindo classification). The overall postoperative mortality was 0.9 %. Multivariate analysis identified the American Society of Anesthesiologists score and splenectomy, but not obesity, as independent risk factors for postoperative complications. The median number of lymph nodes retrieved differed significantly from group to group: obese 21 (IQR 18-26), versus overweight 24, versus normal weight 28 (p = 0.031). No difference was found in lymph node ratio and cancer-related parameters. CONCLUSIONS: Obese patients with operable gastric cancer can be candidates for standard extensive surgical resection, provided that pre-existing co-morbidities and potential intraoperative and postoperative complications are considered.

Financial and clinical implications of low-energy CT combined with 99m Technetium-sestamibi SPECT for primary hyperparathyroidism.

BACKGROUND: (99m)Technetium-sestamibi hybrid SPECT/CT has been favored over conventional SPECT in preoperative evaluation of primary hyperparathyroidism (PHPT) patients. However, the financial implications of CT-image acquisition have never before been published. This prompted us to perform a cost analysis of the aforementioned nuclear procedures. METHODS: A total of 55 PHPT patients operated on between 2004 and 2009 were studied. Overall, 27 patients underwent SPECT and 28 SPECT/CT. Localization results, as well as diagnostic and clinical cost variations between SPECT and SPECT/CT patients, were compared. RESULTS: SPECT/CT revealed higher sensitivity than SPECT (96.7 vs 79.3%; P = .011), as well as higher specificity (96.4 vs 82.4%; P = .037) and positive predictive value (PPV) (96.7 vs 83%; P = .038) for correctly identifying the neck-side affected by PHPT. Likewise, SPECT/CT disclosed higher sensitivity (86.7 vs 61.1%; P < .0001), specificity (97.4 vs 90%; P = .022), and PPV (86.7 vs 65.7%; P = .0001) for correct neck-quadrant identification. The mean operative time decreased from 62 min following SPECT to 36 min following SPECT/CT (P < .0001), yielding a mean surgical expense saving of 109.9 /patient (updated at 2009/2010 billing database). SPECT/CT actually ensures a mean expenditure reduction of 98.7 /patient (95% CI: 47.96 -149.42 ), diagnostic costs variation amounting to 11.2 /procedure. CONCLUSIONS: SPECT/CT ensures better focus for the surgical exploration, shortens surgical times, and eventually cuts costs when used for localization of parathyroid adenomas.

Effects of prophylactic ilioinguinal nerve excision in mesh groin hernia repair: short- and long-term follow-up of a randomized clinical trial.

We conducted a randomized clinical trial on the impact of prophylactic ilioinguinal nerve excision (INE) on neuralgia, hypoesthesia, and analgesia requirement after open herniorrhaphy as well as on sustainability of a selective approach. Ninety-seven consecutive patients undergoing a Lichtenstein procedure were treated with INE (n = 45) or preservation (NP) (n = 52). Impact of patients' age, gender, type of anesthesia, and hernia on outcomes was also evaluated by logistic regression analysis (LRA). Patients receiving INE reported less pain on postoperative days (POD) 1 and 7 and at 1 month and required less analgesia on POD 1. Overall younger patients (40 years old or younger) had more postoperative discomfort at LRA. Pain intensity was similar at 6 and 12 months after INE or NP: moderate to severe pain in 4.4 versus 11.5 per cent (P = 0.279) and 4.4 versus 9.6 per cent (P = 0.445), respectively. Hypoesthesia was more frequent after INE on POD 1 and 7:68.9 and 53.3 per cent versus 13.5 and 9.6 per cent, respectively (P < 0.0001), but no longer at 1 month: 11.1 versus 3.8 per cent (P = 0.244) as well as at 6 and 12 months (0% in both study groups). No further correlation was found by LRA. INE prevents inguinodynia up to 1 month follow-up regardless of patient variables. Moreover, the increase of hypoesthesia proved to be a short-term complication.

Loupe magnification reduces postoperative hypocalcemia after total thyroidectomy.

We aimed to evaluate the impact of loupe magnification (LM) on incidental parathyroid gland removal (from pathology reports), hypocalcemia, and recurrent laryngeal nerve (RLN) injury after total thyroidectomy and answer the question of whether this tool should be always recommended for patient's safety. Between January 2005 and December 2008, 126 patients underwent total thyroidectomy with routine use of 2.5 x galilean loupes; their charts were compared with data on 118 patients operated on between January 1997 and December 2000 without LM (two different equally skilled surgical teams operating in the two periods). LM decreased the rate of inadvertent parathyroid glands removal (3.8 vs 7.8% of total parathyroid glands; P = 0.01), as well as of biochemical (20.6 vs 33.9%; P = 0.028) and clinical (12.7 vs 33%; P = 0.0003) hypocalcemia after thyroidectomy. All cases (16 of 16) of symptomatic hypocalcaemia in the LM group proved to be associated with parathyroidectomy vs 76.9 per cent (30 of 39) without LM (P = 0.046). A trend toward decreased RLN injury rate, although statistically insignificant, was reported, being unilateral transient, unilateral permanent, and bilateral transient palsy rates 6.8, 2.5, and 1.7 per cent, respectively, without LM vs 4.8, 2.4, and 0.8 per cent, respectively, with LM (P = 0.69; P = 1, and P = 0.61, respectively). Our results do support the routine use of LM during total thyroidectomy.

'Ad hoc' sternal-split safely replaces full sternotomy for thyroidectomy requiring thoracic access.

Mediastinal goiter (MG) removal occasionally needs sternotomy, mainly in case of subaortic extension. We aimed to test the hypothesis that sternal-split may safely replace full sternotomy for MG removal (through total thyroidectomy) when thoracic access is required. We conducted a prospective observational cohort study comparing 15 subaortic MGs receiving sternal-split with 87 MGs undergoing cervicotomy alone between January 1997 and June 2009. Among 15 cases requiring sternal incision, sternal-split was extended to the angle of Louis in nine patients (60%), to the third intercostal space (IS) in one of five (20%) cases of MGs with anterior mediastinum involvement, and in five of 10 (50%) cases with posterior involvement (P = 0.6). Full sternotomy was never necessary. The median hospitalization was 5 days (range, 4-8 days) after sternal access as compared with 3 days (range, 2-4 days) after cervicotomy (P = 0.04). Complications were similar in these two study groups: one postoperative bleeding in each group and three recurrent laryngeal nerve palsies after cervicotomy (P = 0.5). There was no operative mortality, blood transfusion, tracheotomy requirement, wound infection, or persistent hypoparathyroidism. Proper extension of sternal-split to the second or third IS allows an adequate approach to both the anterior and to the posterior mediastinum, thus permitting safe management of MGs requiring thoracic access.

Improvement of metabolic syndrome following intragastric balloon: 1 year follow-up analysis.

OBJECTIVE: This study aimed to assess the impact of intragastric balloon (IGB)-induced body weight loss on metabolic syndrome in obese patients and evaluate what happens during 1-year follow-up. METHODS: To this end, data were collected on 143 obese patients (body mass index (BMI) 36.2+/-5.7 kg/m2) who underwent IGB insertion between January 2000 and December 2005. Outcomes were recorded at BioEnterics Intragastric Balloon removal time (t0) and at 6-month (t6) and 12-month (t12) follow-up. RESULTS: Significant BMI, excess body weight loss percentage, and body weight loss percentage (BWL%) were observed at t0 (29.6+/-4.6 kg/m2; 29.3+/-4.8%; 14.1+/-5.7%), followed by partial weight regain at t12 (32.4+/-4.3 kg/m2; 26.1+/-4.9%; 11.2+/-4.6%). Incidence of metabolic syndrome dropped from 34.8% (pre-IGB value) to 14.5% (t0) and 11.6% (t12). Likewise, type 2 diabetes mellitus (DM), hypertriglyceridemia, hypercholesterolemia, and blood hypertension (BH) incidence decreased from 32.6%, 37.7%, 33.4%, and 44.9% (pre-IGB values) to 20.9%, 14.5%, 16.7%, and 30.4% at t0 and 21.3%, 17.4%, 18.9%, and 34.8% at t12. HbA1c blood concentration shifted from an initial value of 7.5+/-2.1% to 5.7+/-1.9% (t0), 5.6+/-0.7% (t6), and 5.5+/-0.9% (t12). Patients suffering from DM or BH stopped or diminished relative drug consumption at t12. Negligible modifications were reported as regards HDL cholesterol and hyperuricemia. CONCLUSION: Weight regain is commonly observed during long-term follow-up after IGB removal. Nevertheless, the maintenance of at least 10% of the BWL%, as reported at 1-year follow-up, is associated with an improvement in metabolic syndrome.

Hereditary multiple exostoses and juvenile colon carcinoma: A case with a common genetic background?

A case of obstructing colon cancer is described in a 31-year-old patient affected by hereditary multiple exostoses. The association of these two rare conditions, which has never been described previously, and their early onset prompt us to discuss the clinical and genetic elements of a potential common pathogenic scenario.

Extension of nonoperative management of blunt pancreatic trauma to include grade III injuries: a safety analysis.

BACKGROUND: In hemodynamically stable patients after blunt pancreatic trauma, the main pancreatic duct (MPD) disruption (American Association for the Surgery of Trauma [AAST] grade III-IV-V lesions) is usually treated surgically or by endoscopic stent placement, whereas injuries without duct involvement (grade I-II) are liable to medical treatment. To date, no evidence has been reported regarding nonoperative management (NoM) of grade III injuries. We aimed to evaluate the safety of extending medical management to include cases of distal MPD involvement (grade III). PATIENTS AND METHODS: Data were collected on patients admitted after blunt pancreatic trauma between January 1999 and December 2007. Patients exhibiting hemodynamic instability or hollow organ perforations were excluded from this study, as they were surgically managed. In all remaining cases NoM was attempted. Antibiotic prophylaxis and early total enteral nutrition were routinely adopted. Grade III patients received octreotide during hospitalization and for 6 months after discharge. RESULTS: Eleven patients (2 with grade I injury, 3 with grade II injury, and 6 with grade III injury, all diagnosed by contrast-enhanced helical CT) were included. Nonsurgical management was carried out in all of these patients. Among grade III patients, one developed a peripancreatic abscess; another, a pancreatic fistula. Both were successfully treated nonoperatively. The average length of hospital stay was similar in grade I-II and grade III patients. After a median follow-up of 57 months no mortality or pancreatic sequelae had occurred. CONCLUSIONS: Under the aforementioned conditions, an attempt to extend NoM to include patients with AAST-grade III lesions can be justified. However, such a strategy demands continuous patient monitoring, because should the case worsen, surgery might become necessary.

APACHE II, POSSUM, and ASA scores and the risk of perioperative complications in patients with colorectal disease.

OBJECTIVE: This study was designed to assess the role of the ASA, POSSUM and APACHE II score systems for predicting the complications in patients undergoing surgery for colorectal diseases. METHODS: We retrospectively analyzed 539 patients undergoing colorectal surgery between January 1996 and December 2006. The accuracy of ASA, POSSUM and APACHE II score systems for predicting perioperative complications has been analysed. RESULTS: Total postoperative morbidity was 15%, overall perioperative mortality was 1.5%. APACHE II and POSSUM predicted with the same accuracy the perioperative complications (0.65 and 0.68, respectively), while ASA score system revealed a poorer predicting accuracy (0.56). POSSUM predicted death rate more accurately compared to the APACHE II classification (1.6% vs. 10.4%). CONCLUSIONS: APACHE II and POSSUM score systems may be useful tools helping surgeons to identify patient groups at high risk for complications. The ASA classification resulted less accurate, probably because related to the anesthesiologist's knowledge.

[Neurological and psychiatric disorders in primary hyperparathyroidism: the role of parathyroidectomy]. / Manifestazioni neuropsichiche in corso di iperparatiroidiso primitivo: il ruolo della paratiroidectomia.

The clinical presentation of primary hyperparathyroidism (pHPT), previously constantly characterized by bone and renal diseases, has been changing during last years. Several Studies report psychic and behavioural symptoms mostly vague and aspecific, particular in elderly patients, such as asthenia, anxiety, depression, irritability, mood swings, amnestic and cognitive disturbances, severe psychosis. In case history hereby reported 11.8% of the patients affected by pHPT (16 out of 136 cases operated from 1983 to October 2006) who underwent to parathyroidectomy, presented only neuro-cognitive and/or psychiatric symptoms. A relevant association has been found between clinical presentation and age: patients showing neuro-cognitive and psychiatric disturbances were older compared to those suffering from the classical bone and kidney disease. No significant correlation neither with serum calcemia nor with PTH serum levels and severity of the symptomatology was demonstrated A statistically significant reduction of the anxious-depressive disturbances one month post surgery has been found (p < 0.05), and an improvement, though not significant, of the neuro-cognitive and psychiatric alterations was registered (p > 0.1). The Authors believe neuro-cognitive or psychic manifestations is not to be neglected, mainly in geriatric patients: frequently the aspecific symptomatology is not referred as hypercalcemia due to pHPT Neuro-psychic symptomatology should be considered an indication for surgical treatment.

[The obstructive sleep apnea in bariatric surgery]. / Sindrome delle apnee ostruttive del sonno in chirurgia bariatrica.

INTRODUCTION: Obesity is a well known risk factor for obstructive sleep apnea (OSA). Medical therapy is not effective for morbid obesity. Bariatric surgery is therefore a reasonable option for weight reduction for patients with clinically severe obesity. PATIENTS AND METHODS: 283 obese patients were operated on from 1999 until 2005 in our Institution and they were examined with a history, physical examination and the Epworth Sleepiness Scale (ESS). Obese patients with a ESS score > or = than 10 were evaluated with a Polysomnography (PSG). RESULT: 61 patients (21.5%) resulted with a ESS > or = than 10. An obstructive sleep apnoea syndrome was identified in 52 patients (85.2%). These patients were treated by continuous positive airway pressure (CPAP) for 3 months before the surgical treatment. After 1 year follow-up (100% of patients) we observed a reduction in OSAS patients: ESS < 10 in 77.5% and PSG negative in 80.3%. CONCLUSION: This study considered the value of ESS to select obese patients with a high risk of OSA. We did not observe any association between grade of obesity and risk of OSA. Bariatric surgery reduced the prevalence of OSA already after 1 year of follow-up and the preoperative treatment of OSA (3 months CPAP) reduced the post-operative morbidity.

Modifiable risk factors in colorectal surgery: central role of surgeon's volume.

BACKGROUND: Our objective was to inform the ongoing debate regarding selective referral of colorectal cancer patients to high-volume surgeons in order to improve outcomes. PATIENTS AND METHOD: We evaluated data on patients treated by colorectal-dedicated surgeons (first study-group) and non specialized surgeons (second study-group). Particular attention has been paid to patients selection in order to collect two study-groups with similar demographic and clinical characteristics, differing only as regards providers' surgical experience in the colorectal field. We focused on postoperative mortality and 5-year overall and cancer-specific survival. We also analyzed resection rates of the primary tumor and colostomy rates for patients with stage I to III rectal cancer, and use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer by surgeon's volume. RESULTS: The analysis of these 2 study-groups shows better results for patients treated by colorectal-trained surgeons (high-volume surgeons) for each parameter taken into account: lower postoperative mortality (OR 0.32; 95% CI:0.7-0.1; p = 0.04), increased 5-year overall and cancer specific survival (rising from 41.2% and 46.4% to 56% and 61.2% respectively; OR 1.8; 95% CI: 1.3-2.6; p < 0.005). Patient treated by non specialized surgeons are more likely to receive a permanent colostomy (abdominoperineal resection: APR) (OR 5.9; 95% CI: 3.3-10.7) and to undergo a non-resective procedure (OR 4.8; 95% CI: 1.9-12)(p < 0.005). No difference was found between the 2 study-groups in the use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer. CONCLUSIONS: Our analysis suggests that surgeon's volume does impact on outcomes for patients undergoing surgery due to colorectal cancer.

[Takayasu's arteritis in Crohn's disease: a case report]. / Arterite di Takayasu in morbo di Crohn. Caso clinico.

The authors describe a case of Crohn's disease associated with Takayasu's arteritis. The coexistence of these two diseases has been previously reported in 28 subjects. The late onset of Crohn's disease, particularly in relation to that of the arteritis, and colonic involvement were peculiar features of the present case. Aetiopathogenetic theories regarding the association are discussed after reviewing previous case reports.

Still a role for surgery as first-line therapy of splenic marginal zone lymphoma? Results of a prospective observational study.

AIM: Assessment of hematologic improvement, survival and peri-operative morbidity after first-line splenectomy for splenic marginal zone lymphoma (SMZL). METHODS: Forty-three patients undergoing open splenectomy were prospectively analyzed. Perioperative clinical course, overall and progression-free survival (OS-PFS) were evaluated. Risk factors analyzed were gender, age, ASA-grade, ECOG performance status, presence of B-symptoms, body mass index, steroidal treatment, serum albumin concentration, IIL-score, operative time, spleen size and weight. RESULTS: The median follow-up was 31 months (IQR 15-76; range 24-154). Anemia and thrombocytopenia resolved in 80% of patients at 6 months; in 60% at 2 years. The 5-year and 10-year PFS were 35% and 13% respectively, with a median of 35 months (shorter in patients with ECOG performance status ≥2 and B-symptoms). Nineteen cases (44.2%) had a progression of disease within 2 years. Of these, 14 (32.6%) received adjuvant chemotherapy (mainly R-FC or R-CVP). Progression was attributed to high-grade B lymphoma in 7 (16.3%) patients. The median time between diagnosis and progression to aggressive lymphoma was 25.5 months (range 18.8-81.8). The median time to next treatment was 83.5 months (95% CI 49-118). The 5-year and 10-year OS were 75% and 53% respectively. Mortality was due to disease progression and histological transformation in high-grade B lymphoma in 50% of cases, myelodisplastic syndrome in 15%, recurrence of hemolytic anemia in 15%, Hodgkin lymphoma in 7% and to infections (mainly pulmonary) in the remaining 13% of cases. Post-operative morbidity was 2.3% (1 patient with grade-3 complication). Overall grade ≥2 complication rate was 32.5% (mainly hemorrhagic and pulmonary complications). Spleen weight was the only independent risk factor for morbidity. Mortality was nil. CONCLUSION: Splenectomy is safe and effective as regards cytopenia resolution and OS, although disease progression is frequently observed at follow-up. Such results are strictly linked to accurate pre- and post-operative clinical management and optimal anesthesiologic approach.

[Methods of intraoperative localization in the surgery treatment of persistent and recurrent secondary hyperparathyroidism]. / Metodiche di localizzazione intraoperatoria nel trattamento chirurgico degli iperparatiroidismi secondari persistenti e recidivi.

The intraoperative localization of residual parathyroid tissue during re-operations for persistent or recurrent secondary hyperparathyroidism (HPT) could have difficult due to cicatricial phenomena, anatomic modifications, ectopic or super-numerous glands. The use of intraoperative localisatin methods, as ultrasonographic and gamm-camera, permits a great level of success in identifying residual gland tissue. The Authors report their experience in the treatment of 5 cases of persisten HPT and 3 cases of recurrent HPT using gamma-camera and ultrasonography intraoperatively. Gamma-camera presented a sensitivity of 88% while ultrasonography did 100%. According to the experience, even numerically limited, of the Authors, intraoperative ultrasonography offers better results than gamma-camera, with less technical complexity.