201 cases of foreign body ingestion in a Surgical Emergency Unit A 16-year retrospective study.

AIM: The aim of this study is to analyse clinical characteristics of FB ingestion and predictive factors for complications, in order to reduce mortality and morbidity. MATERIALS AND METHODS: A retrospective study of emergency surgical consultation records has been carried out from June 2005 through June 2015 yielded 201 episodes with the diagnosis of ingestion of foreign objects at the Surgical Unit of the University of Bari. RESULTS: Natural Removal in 44,8% of cases; Endoscopic retrieval in 42,4%, Surgical Procedures 4,4%. Statistical analysis was based on multivariate analysis and the model R2 of the Naegelkerke value. DISCUSSION: First of all, the approach to ingestion should be endoscopic. The second approach is surgical in selected cases. The most frequent site of impaction were oesophagus, stomach and right colon. An EGD proved to be the most used procedure with a no morbidity and no mortality. CONCLUSION: The ingestion of foreign bodies is a frequent, complex and expensive condition to treat. Observation and endoscopy are the most appropriate procedures to be considered to manage the ingestion of FB in Emergency Surgery Unit. KEY WORDS: Emergency surgery, Foreign bodies, Ingestion.

Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience.

OBJECTIVES: Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS: Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS: Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.

Predictive factors for incidental gallbladder cancer (IGBC) in patients undergoing cholecystectomy for presumed benign disease. A single-center experience.

AIM: The incidence of incidental gallbladder cancer (IGBC) is estimated at 0.3-2.1%. The purpose of our study is to evaluate IGBC incidence in our department and to establish its predictive factors, considering patients' clinical characteristics and pre-operative ultrasound gallbladder features. MATERIAL OF STUDY: From January 2012 to December 2015, 434 patients (225 females and 209 males) were enrolled in this retrospective observational study in our General Surgery Department. To analyze potential predictive factors, we divided all the patients into two groups: patients with and without histological diagnosis of IGBC. We focused our attention on the patients' clinical characteristics and preoperative ultrasound gallbladder measurements RESULTS: Seven cases were post-operatively identified as incidental gallbladder cancer (IGBC) and after histological examination an IGBC incidence of 1.6% was encountered. DISCUSSION: Considering the increasing numbers of video laparoscopic cholecystectomies (VLC) performed worldwide, cases of IGBC are appearing more frequently. In most cases of IGBC, a second surgical look will be necessary because of feasibility and safety procedures. CONCLUSIONS: There is no possibility to establish which risk factors might be predictive for IGBC because of a discordance in the literature and a statistical analysis with low sample size. An accurate surgical procedure needs to be performed to reduce the spread of neoplastic cells and, as a result, improve long-term outcomes. KEY WORDS: Incidental Gallbladder cancer, Laparoscopy, Ultrasound.

Surgical approach for ulcerated locally advanced breast cancer. A single Center experience: a retrospective study.

AIM: The aim of our retrospective study is to analyze surgical possibilities for the extended LABC in those cases not suitable for a neoadjuvant chemotherapy step and to consider various reconstruction techniques. MATERIAL OF STUDY: Between 2009 and 2015 we enrolled 11 patients, admitted to the Emergency Department, presenting ulcerated LABC that needed palliative surgical demolitive procedures because of bleeding and anemia and in which was necessary to use natural tissues transposition or synthetic substitutes for the reconstruction of the skin flaps. RESULTS: The mean follow up was 12 months. Mortality rate was 82% (9 patients); in 2 cases there was local relapse after 6 months; 9 months was the longest disease free survival. DISCUSSION: Thanks to multidisciplinary strategies LABC's surgical treatment improved results with a five-year survival rate between 30-40% and better quality of survival. Despite extended demolitive approach, there is still a 50% of death because of metastases. CONCLUSIONS: Our results confirm that musculocutaneous flap, skin anterior thigh grafts, bilayer matrix wound dressing are excellent reconstructive strategies in locally advanced ulcerated breast cancer after aggressive extended surgery even if palliative to improve patients' further survival. Our data also showed that those patients presenting medium level of malignancy as "luminal b" subtype (7 patients) if treated earlier with a radical surgical procedure would have better prognosis. KEY WORDS: Oncoplastic techniques, Ulcerated breast cancer.

Cellular and humoral inflammatory response after laparoscopic and conventional colorectal surgery. Preliminary report.

Our aim is to compare the immune response after colorectal surgery performed laparoscopically and via traditional technique. This response seems to be proportional to the level of the surgical trauma and presumably is directed to improve host defence. This is a prospective reported study based on patients' randomisation. Fourteen patients with colorectal diseases undergoing laparoscopic or open surgery were enrolled. After both laparoscopic and open colorectal surgery, we observed a significant increase of circulating C-Reactive Protein (CRP) levels. The count of lymphocytes subpopulations did not show significant differences after both procedures. IL-6 serum levels increased immediately after laparoscopic approach. IL-6 production was preserved only in the laparoscopic group, while its plasma levels were significantly higher in conventional group. Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Laparoscopy became a popular approach to treat surgically benign and malignant colorectal diseases and several authors reported a better immune response in patients performing laparoscopic surgery after comparing to conventional colorectal surgery. These findings may have important implications in performing a laparoscopic colorectal resection. KEY WORDS: C-Reactive Protein IL-6, Laparoscopic Surgery.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Choledochal cysts in pregnancy A case report and literature review.

AIM: Aim is to demonstrate that surgery can be the best way to reduce the risk of malignancy in choledochal cysts (CC) and how hard can be the diagnosis and the treatment during pregnancy. CASE REPORT: We report a case of a pregnant young woman (36 week) with a Todani's score II CC. After caesarean, due to increasing jaundice, she underwent magnetic resonance cholangiopancreatography (MRCP) and Endoscopic retrograde cholangiopancreatography (ERCP) that confirmed the diagnosis. Surgical operation consisted in "cholecystectomy, resection of the choledocal cyst and poli-jejunum anastomosis. drainage of the abscess in the iv hepatic segment". DISCUSSION: This case report highlights the difficult diagnosis and consequently treatment of a CC, especially during pregnancy. A significant association of biliary duct cyst and hepato-bilio-pancreatic malignancy has been reported with an age-related incidence. CONCLUSION: Surgery is considered as the best treatment with a close follow-up because of the risk of recurrent cholangitis and malignant degeneration. This case represents also a challenge because of physiological changes in pregnancy and also because of the risk of fetal mortality and maternal morbidity. KEY WORDS: Choledochal cyst, Colangiocarcinoma, Pregnancy, Todani's score.

Laparoscopic management of pancreatic cancer. Our experience.

AIM: Minimally invasive techniques have a definite role in the surgical treatment of several gastrointestinal tract cancers but there is still no widespread use of the laparoscopic approach for cancers of the head of the pancreas. The aim of this retrospective study is to review our experience from 2003 to 2013 in the management of pancreatic cancer with particular emphasis on the clinical application of minimally invasive techniques. METHODS: One hundred fifty-eight pancreatic cancer patients (median age 69,7±12,6 years) with obstructive jaundice were enrolled in our study. One hundred eighteen (74,7%) had an endoscopic biliary stent, 68 patients (43,03%) were eligible for surgery. Only 22 of the patients eligible for surgical intervention underwent pancreaticoduodenectomy (PD): 14 had open PD and 8 had laparoscopic PD (LPD). Thirteen of the PD patients had a pylorus-preserving procedure (8 open and 5 laparoscopic procedures) whereas in 9 the pylorus was not preserved (6 open and 3 laparoscopic procedures). The other 46 patients had un-resectable tumors and 34 of them underwent palliative surgery consisting of gastrojejunal and hepatojejunal anastomosis (18 open and 6 laparoscopic procedures), and gastrojejunal anastomosis in 10 patients (4 open and 6 laparoscopic procedures). Ten patients had only explorative laparoscopy and 2 only explorative laparotomy. RESULTS: The resectability rate was 13,9%. The median age in patients treated with an endoscopic biliary stent was significantly higher than in those who underwent surgery (73,2±13,3 years vs 64,4±9,6 years; p < 0,05). Operative time in LPD patients was significantly longer than in PD patients (521±68 minutes vs 381±88 minutes; p<0.05). The hospital stay of patients who underwent PD was significantly longer than that of those who underwent palliative surgery (27±4 days vs 10±5 days; p < 0.05). in PD patients the morbidity rate was 22,72 % and the mortality rate 4.5%. CONCLUSIONS: In recent years laparoscopic surgery has become very important in oncologic surgery because it is minimally invasive and reduces postoperative complications and because there is sufficient evidence based data showing that results in terms of complications and survival are as good as the results of conventional surgery. However the learning curve for laparoscopic cancer surgery of the head of the pancreas is steep and our results indicate that in LPD operative time is significantly longer than in PD, and moreover the laparoscopic approach is not associated with a shorter hospital stay. Therefore LPD should be performed only in well-established laparoscopic and oncological centers with a multidisciplinary team. KEY WORDS: Laparoscopy, Pancreatic cancer, Pancreaticoduodenectomy.

[The role of laparoscopy in surgical treatment of pancreatic cancer]. / Il ruolo della laparoscopia nel trattamento chirurgico del carcinoma pancreatico.

AIM: The authors reviewed their experience in surgical treatment of pancreatic cancer between 2003-2008. METHODS: Eighty two pancreatic cancer patients (median age 66.7 +/- 12.5) with obstructive jaundice were enrolled in our study: 36 (44%) had an endoscopic biliary stent; 46 patients (56%) were eligible for surgery: 14 received a curative surgery (pancreatoduodenal resection; 4 had a laparoscopic procedure) and 32 patients with non resectable tumor a palliative surgery: 18 had a gastro-jejunal with a biliary anastomosis (in 4 patients the hepatic-jejunal anastomosis was performed in laparoscopy), 6 had a gastro-jejunal anastomosis (2 laparoscopic procedure and 8 patients had only an explorative laparoscopy. RESULTS: The resectability rates was 17.1%. Median age in patients treated with endoscopic biliary stent was significantly higher than those underwent surgery (72.3 +/- 12.2 vs. 63.5 +/- 9.6; p < 0.05). Hospital length of stay in patients underwent radical surgery was significantly higher than those who received palliative surgery (18 +/- 6 vs. 10 +/- 5; p < 0.05). Morbility rate, including operative mortality of .3%, was 15.2%. CONCLUSIONS: Laparoscopy is largerly used in major oncologic surgery for several reasons: it minimized surgical manipulations and so post-operative complications. There is enough scientific evidence of low incidence of post-operative complications and long-term results compared to those achieved with traditional surgery.

Phase III randomized multicenter study on the effects of adjuvant CMF in patients with node-negative, rapidly proliferating breast cancer: twelve-year results and retrospective subgroup analysis.

The randomized multicenter study on rapidly proliferating breast cancer, assessed according to thymidine labelling index (TLI), was activated at the end of the 1980s. The present work investigated whether and to what degree the short-term advantages observed from adjuvant CMF (cyclophosphamide, methotrexate, 5-fluorouracil) were maintained at a longer follow-up. Two hundred and eighty-one patients with node-negative and high TLI tumors were randomized to receive six cycles of CMF or no further treatment. At a median follow-up of 12 years, CMF produced a 25% and 20% relative reduction in relapse and death cumulative incidence, respectively. A breakdown analysis identified a subgroup of patients with intermediate proliferating tumors for whom a 70% and 73% reduction in relapse and death was observed in the intention-to-treat population. An even higher reduction of 80% and 84% in relapse and death was seen for the patients who had received the full CMF dose. We identified a subgroup of patients with intermediate proliferating tumors in whom the high benefit obtained from adjuvant CMF was maintained at a long-term follow up.

Do serum angiogenic growth factors provide additional information to that of conventional markers in monitoring the course of metastatic breast cancer?

OBJECTIVE: Our work evaluated the potential role of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) serum levels with respect to that of conventional serum tumour markers, CEA and CA 15-3, in monitoring the course of metastatic breast cancer in 56 female patients treated with cytotoxic chemotherapy. METHODS: VEGF and bFGF concentrations were determined using a quantitative sandwich enzyme immunoassay technique. The positive predictive value (PPV) of each marker and of marker combinations for different types of clinical response was calculated. RESULTS: The highest PPV for overall disease control was shown by bFGF (70%), which also showed the highest PPV for both partial response (36.4%) and stable disease (63.2%). CEA showed the highest predictive value for progression (69.2%). A combined increase in CEA and bFGF or VEGF was associated with disease progression in all patients. CONCLUSIONS: Information provided by angiogenic factor levels seems to be independent of and is possibly complementary to that provided by conventional serum markers. bFGF showed the maximum predictive value for disease control and provided additional information to that obtained from CEA or CA 15-3 evaluation. It could therefore be a promising candidate for monitoring response to chemotherapy in advanced breast cancer.

Usefulness of immunological detection of the human telomerase reverse transcriptase.

OBJECTIVE: Recent years have seen a considerable wealth of studies conducted on the potential usefulness of telomerase determination in diagnosis, prognosis and targeted cancer therapy. The frequently used Telomeric Repeat Amplification Protocol assay suffers from some drawbacks, the most important being the rate of false positives. In situ analysis using well characterised antibodies directed against the human telomerase reverse transcriptase (hTERT) would therefore appear to be important to morphologically identify the nature of telomerase positive cells. METHODS: We performed immunostaining in a series of cultured cells and in normal, preneoplastic and tumour tissues from different organs using a monoclonal antibody directed against the catalytic subunit of telomerase. RESULTS: Immunoreactivity was not observed in perennial cells of terminally differentiated cardiac and skeletal muscular tissues or in small pyramidal cells of the cerebral cortex. Conversely, it was found in other normal somatic tissues as well as in precancerous lesions and in all tumour histotypes. CONCLUSIONS: Immunohistochemistry with a well characterised hTERT-specific monoclonal antibody permitted the identification of hTERT immunopositive cells in normal somatic tissues. Whether hTERT protein detected by immunostaining with hTERT-specific Tel 3 36-10 antibody is actually the degraded form of the protein that retains hTERT antigenicity but not enzymatic function, or whether it represents the real, potentially functional catalytic subunit of the enzyme, immunohistochemistry would not seem to represent a useful tool to investigate the role of telomerase and the mechanisms involved in its regulation.

Prognostic relevance of histological grade and its components in node-negative breast cancer patients.

Available results highlight the lack of good level of evidence studies on the pure prognostic value of histological grade. In the present study, the prognostic relevance of histological grade and of its three components, tubule formation, nuclear pleomorphism and mitotic count, was analyzed in a series of 372 patients with node-negative breast cancer treated with locoregional therapy alone until early relapse. Histological grade was determined blindly by two observers and discordance between evaluations was resolved after joint review using a multihead microscope. No relation was observed between histological grade and any of its three components and disease-free survival. Conversely, a significant relation was observed between histological grade and distant metastasis-free survival (at 6 years, 94, 86 and 76% for grades 1, 2 and 3, respectively, P=0.013) as well as overall survival (98, 90 and 86%, P=0.001). A breakdown analysis as a function of the three components showed that neither tubule formation nor nuclear pleomorphism was associated with prognosis, and only mitotic count strongly influenced both distant metastasis-free survival (91, 82 and 74%, P=0.014) and overall survival (97, 87 and 85%, P=0.011). Histological grade suffers from a much higher subjectivity than any other microscopic evaluation of biomarkers as it is the sum of three different morphological features. Within the Italian Network for Quality Assessment of Tumor Biomarkers program we observed that histological grade is an independent prognostic variable, but also that this role is ascribable only to the number of mitotic figures. In conclusion, due to the ever smaller size of diagnosed breast cancers, resulting in less cancer tissue for biofunctional and molecular analysis, mitotic count evaluated under strict quality control conditions seems to be an accurate and feasible prognostic variable.

Basic fibroblast growth factor and vascular endothelial growth factor serum levels in breast cancer patients and healthy women: useful as diagnostic tools?

INTRODUCTION: The aim of the present study was to analyze the relationship between the expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in breast cancer cells and the corresponding serum levels in individual patients. The study also evaluated the potential of serum levels of the two growth factors as diagnostic markers in a case-control study. METHODS: VEGF expression and bFGF expression were determined in 62 and 63 tumor samples, respectively. Serum VEGF and bFGF levels were determined in 54 and 65 healthy women and in 69 and 73 breast cancer patients, respectively, using a quantitative sandwich enzyme immunoassay technique. RESULTS: A direct correlation was observed between VEGF expression and bFGF expression in individual tumors (P = 0.001) and between serum levels (P = 0.038) in individual patients, but not between tumor cell expression and the corresponding serum level for either growth factor. Median values of serum levels in healthy women and breast cancer patients were not different for VEGF (P = 0.055), but were significantly different for bFGF (P < 0.001). The receiver operating characteristic curve identified a serum bFGF concentration of 1.0 pg/ml, with 84.9% sensitivity and 63.1% specificity, as the best cut-off value to discriminate between healthy women and breast cancer patients. An age-based subgroup analysis showed that serum values of patients older than 70 years of age mainly contributed to the high accuracy. CONCLUSIONS: Our data repropose bFGF as a noninvasive diagnostic tool for breast cancer.

Prognostic relevance of mitotic activity in patients with node-negative breast cancer.

The prognostic relevance of mitotic activity was analyzed in a series of 306 patients with node-negative breast cancer treated with locoregional therapy alone, until early relapse. Mitotic activity was evaluated as the number of mitotic figures per 10 high-power fields (mitotic activity index) or per 1000 tumor cells (mitotic index). Counting was carried out blindly by two observers. A high correlation was observed between the two determinations (r(s) =.96, P <.001). For clinical analysis, three mitotic activity index subgroups (mitotic figures/field

HER-2 expression and cell proliferation: prognostic markers in patients with node-negative breast cancer.

PURPOSE: We analyzed the clinical relevance of HER-2 expression, widely investigated in breast cancer but with contradictory results, in the largest case series of node-negative breast cancer patients investigated to date. PATIENTS AND METHODS: The pure prognostic value of HER-2 expression was investigated in 529 patients treated with locoregional therapy alone until early relapse. Proliferative activity was evaluated as [3H]thymidine labeling index and HER-2 expression by immunohistochemistry. All biologic determinations were conducted within the context of an intra- and interlaboratory National Quality Control Program. RESULTS: HER-2 expression was not related to relapse-free survival in the overall series but was a significant discriminant of prognosis in the subgroup of patients with rapidly proliferating tumors. Six-year rate of relapse was 40% for patients with highly (> or =30%) positive tumors and 26% for those with weakly HER-2-expressing tumors (P =.039). CONCLUSION: HER-2 expression in association with proliferative activity identifies a subgroup of node-negative breast cancer patients with the worst prognosis, who are candidates for specific intensive adjuvant therapy.

Vascular endothelial growth factor and prognosis in patients with node-negative breast cancer.

Vascular endothelial growth factor (VEGF) has emerged as one of the most important angiogenic growth factors from experimental in vitro and in vivo studies. In the present study, we investigated the relationship between VEGF expression and microvessel density (MVD) and defined their prognostic relevance on a series of 242 patients with node-negative breast cancer, using immunohistochemical methods. In parallel, estrogen and progesterone receptors were quantitatively assessed using the dextran-charcoal technique and cell proliferation was evaluated as S-phase cell fraction according to (3)H-thymidine-labeling index (TLI). The percentage of VEGF-expressing cells varied from 0-95% in the different tumors and was unrelated to menopausal status, tumor size or steroid receptor status. Conversely, a significant inverse relation was observed with patient age or tumor cell proliferation, albeit with very poor correlation coefficients. A significant relation was observed between VEGF expression and MVD (r(s) = 0.55, p < 0.001). Clinical outcome analyzed as a function of high and low VEGF expression showed slight differences in terms of both disease-free survival (DFS) and overall survival (OS) that never reached statistical significance. Moreover, the trend was paradoxically in favor of patients with highly VEGF-expressing tumors. Finally, DFS and OS curves, when analyzed as a function of VEGF expression or MVD, were superimposable. In conclusion, our study did not highlight a prognostic relevance of VEGF expression in patients with node-negative breast cancer, as already observed for MVD.

p27/kip1 expression in normal epithelium, benign and neoplastic breast lesions.

The development of cancer in the breast and in other sites is a complex process requiring a number of different genetic and epigenetic alterations. The accumulation of the genetic changes is thought to underlie the progression from precancerous lesions to carcinomas. The expression of p27/kip1 protein, a cyclin-dependent kinase inhibitor, was investigated by immunohistochemistry in normal epithelial specimens, benign alterations, and malignant lesions of the breast. The number of p27/kip1-positive cells ranged from none to more than 98% in the overall series. Wide ranges of p27/kip1-positive cells were consistently observed within each histological category, but the median value progressively decreased in typical hyperplasia and fibroadenoma, with an even more marked reduction in malignant lesions, compared with normal epithelium. Moreover, the percentage of cells expressing p27/kip1 in tumours was about three times lower in invasive than in in situ lesions and was inversely related to tumour size, but not to lymph node involvement. In conclusion, the degree to which p27 expression is altered in typical hyperplastic lesions and fibroadenomas indicates that the deregulation of p27 may occur very early on during breast cell transformation, but the usefulness of its determination to categorize subgroups of lesions at different risk of evolution remains somewhat doubtful.