Toward Environmentally sustainable surgery: Waste recycling in general surgery operating room. Preliminary cognitive audit.

BACKGROUND: It is common practice to classify waste from the operating theater as "clinical". The development of sustainable policies could have a significant impact. In the first phase, our study aims to measure general surgery waste and to assess the potential financial and carbon savings of appropriate recycling. Based on this information, we will plan for a second phase in which educational interventions will be put in place to promote waste segregation in surgical environments. METHODS: We conducted a preliminary cognitive audit of the most common general surgery procedures to examine the types and quantity of waste produced. We calculated the economic and environmental impacts of disposing of waste treated as clinical or general, and we measured how much of it could actually be recycled. Then, we attempted a projection of the savings we could expect if recycling policies were implemented. RESULTS: We found that more than 30% of total waste was actually recyclable. Considering a projection based on annual procedures performed in our hospital, we estimated that for each kind of surgical procedure, we could expect a reduction of the carbon footprint by approximately 6%, and an average 3% reduction in costs every year, only by improving waste segregation in the general surgery operating rooms. CONCLUSION: There could be a great potential for reducing environmental and economic footprint of the operating rooms by promoting waste recycling protocols. Surgeons are in a unique position to implement for these protocols. Interventions should be codesigned with theater staff to create a "green culture".

Psychopathological factors and personality dimensions on dysfunctional eating behaviors in a sample of individuals with obesity.

Introduction: Obesity and eating disorders are considered to be part of a broad spectrum of disorders associated with weight issues and maladaptive eating styles. Several studies show that psychopathological and personality characteristics contribute to the development and maintenance of obesity and dysfunctional eating behaviors, showing a bidirectional relationship. The purpose of this study was to understand the role of psychopathological factors and personality dimensions on dysfunctional eating behaviors in a sample of individuals with obesity. Methods: The study was conducted with 96 individuals with obesity (31 males and 65 females) who underwent psychological assessment. The instruments administered included the Cognitive Behavioral Assessment 2.0 - Primary Scales, the Minnesota Multiphasic Personality Inventory-2, and the Eating Disorder Inventory. Relationships between dysfunctional eating behaviors and personality and psychopathological factors were explored through mediation analysis. Results and discussion: Our results showed that difficulties related to impulse control and behavior, along with negative and dysphoric emotions, may be associated with difficulties in eating behavior. Mediation analysis showed that the combination of depressive and obsessive-compulsive symptomatology may exacerbate or contribute to the occurrence of eating disorders. These psychopathological aspects should be taken into account during the assessment of patients who decide to undergo bariatric surgery and should be targets of specific psychological interventions.

Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study.

BACKGROUND: Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE: This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN: Multicenter retrospective study. SETTINGS: Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS: Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES: The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS: Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS: The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS: Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).

Sarcopenia and visceral fat in patients with incisional hernia after urgent laparotomy.

PURPOSE: Various risk factors have been associated with the development of incisional hernia (IH). Some recent papers underlined that visceral fat could be a reliable indicator. Another risk factor which is of increasing clinical interest is sarcopenia. Recent studies have identified it as an independent predictor of poor postoperative outcomes following abdominal surgery. We aimed to investigate the role of visceral fat and skeletal muscle as emerging risk factors for IH after urgent laparotomy. METHODS: Patients aged 18 years or older who underwent urgent median laparotomy and with continuous direct suturing of the laparotomy were included. They were categorized into two groups: those with a median IH and those without IH at 12-month follow-up. Demographic data were prospectively collected while CT scans were retrospectively reviewed. The data were compared among two groups. RESULTS: From January 2018 to May 2021, 364 patients underwent urgent surgery in our Department, of whom 222 were aged >18 years old and underwent median laparotomy. Forty-four patients had diagnosis of median IH, while 41 patients without IH were identified as the control group. Statistically significant differences emerged for BMI and for the area of visceral fat. The association with the presence/absence of sarcopenia was not significant. CONCLUSION: Even when surgery is performed in urgent settings, it could be important to identify patients at risk, especially as CT scans are generally available for all patients with urgent abdominal disease.

Proctological disorders: psychometrics assessment of personality features and clinical evaluation.

Patients with gastrointestinal diseases have been shown to report greater stress, anxiety, depression and obsessive-compulsive characteristics. The aim of our study is to investigate personality characteristics and general distress of adult patients suffering from common coloproctological conditions. We conducted a retrospective observational study including patients aged 18 years or older, with diagnosis of haemorrhoidal disease (HD group) or anal fissure (AF group). The final sample was composed of 64 participants, who were asked to complete a battery of questionnaires. They were compared with a control group of healthy volunteers. In terms of general distress, HD group scored higher than both the CG and AF groups. The two proctological groups had higher scores in neuroticism/emotional lability compared to the CG group. In the MOCQ-R scale (obsessive-compulsive tendency), HD group had significantly higher scores compared to the CG group in the total score (p < 0.01,) and also scored higher in the doubting/ruminating subscale compared to the AF group. We support the importance of taking a multidisciplinary perspective and incorporating psychometric tools to assess the psychological and personality dimensions of patients into proctological clinical practice. The correct early evaluation and management of these conditions may result in an improvement in patients' quality of life and better response to treatment.

Impact of Preoperative Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios on Long-Term Survival in Patients with Operable Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has an extremely poor prognosis. The outcomes of patients with cancer are determined not only by tumor-related factors but also by systemic inflammatory response. The objective of the study was to identify whether the preoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are associated with the prognosis of PDAC of the pancreas head after curative pancreatoduodenectomy. MATERIALS AND METHODS: Seventy-six patients were enrolled in this prospective, observational clinical study. The optimal NLR and PLR cut-off values were calculated using a receiver operating characteristic (ROC) curve analysis. ROC curve analysis revealed an optimal NLR and PLR cut-off point of 5.41 and 205.56, respectively. Consequently, the NLR and PRL scores were classified as NLR <5.41 or ≥5.41 and PLR <205.56 or ≥205.56. The clinical outcomes of overall survival (OS) and disease-free survival (DFS) were calculated by Kaplan-Meier survival curves. Univariate and multivariate analyses were performed to analyze the prognostic value of NLR and PLR. RESULTS: Low preoperative NLR and PLR levels both correlated with better pathological features, including decreased depth of invasion (p < 0.001), less lymph node metastasis (p < 0.001), earlier stage (p < 0.001), and lymphovascular invasion (p = 0.004). Kaplan-Meier plots illustrated that higher preoperative NLR and PLR had does not influence OS and DFS. Univariate analysis revealed that depth of invasion, lymph node metastasis, stage, PLR, and NLR are risk factors affecting OS and DFS. Multivariate analysis revealed that only stage was independently associated with OS and DFS. CONCLUSIONS: NLR and PLR measurements cannot provide important prognostic results in patients with resectable PDAC.

Antitumor Potential of Immunomodulatory Natural Products.

Cancer is one of the leading causes of death globally. Anticancer drugs aim to block tumor growth by killing cancerous cells in order to prevent tumor progression and metastasis. Efficient anticancer drugs should also minimize general toxicity towards organs and healthy cells. Tumor growth can also be successfully restrained by targeting and modulating immune response. Cancer immunotherapy is assuming a growing relevance in the fight against cancer and has recently aroused much interest for its wider safety and the capability to complement conventional chemotherapeutic approaches. Natural products are a traditional source of molecules with relevant potential in the pharmacological field. The huge structural diversity of metabolites with low molecular weight (small molecules) from terrestrial and marine organisms has provided lead compounds for the discovery of many modern anticancer drugs. Many natural products combine chemo-protective and immunomodulant activity, thus offering the potential to be used alone or in association with conventional cancer therapy. In this review, we report the natural products known to possess antitumor properties by interaction with immune system, as well as discuss the possible immunomodulatory mechanisms of these molecules.

Systemic inflammation response index (SIRI) as predictor of anastomotic leakage after total gastrectomy for gastric cancer.

BACKGROUND: Esophago-jejunostomy leakage (EJL) it the most dreaded septic complication after total gastrectomy for gastric cancer. Early detection and treatment of this complication may improve outcomes. Systemic Inflammation Response Index (SIRI) is a marker that reflects systemic inflammation. METHODS: The SIRI was developed in a training cohort of 180 patients who underwent elective open total gastrectomy with esophago-jejunal anastomosis for gastric cancer from January 2009 to December 2013. To verify the prognostic value of SIRI score we recruited 192 patients treated from January 2014 to December 2021 as the validation cohort. The optimal cut-off value of SIRI was determined by receiver operating characteristic curve. Univariate and multivariate analysis was performed. RESULTS: An optimal cut-off point for the SIRI of 0.82 divided the patients into a low SIRI group and high SIRI group in the training cohort. Patients with a SIRI ≥0.82 was found to be significantly associated with EJL. Univariable analysis showed that NLR, PLR, MLR, SII, and SIRI were prognostic factors for EJL in the training cohort. In multivariable analysis, EJL high level of SIRI was identified as independent prognostic factor. CONCLUSIONS: Preoperative SIRI may be helpful in identifying patients at greater risk for developing EJL after total gastrectomy.

Identification of the Marine Alkaloid Lepadin A as Potential Inducer of Immunogenic Cell Death.

Natural products and their synthetic analogs and derivatives are a traditional source of bioactive molecules with potential development as drug candidates. In this context, Marine Natural Products (MNPs) represent a rich reservoir of diverse molecular skeletons with potential pharmacological activity that, so far, has been mostly explored in cancer and infectious diseases. Starting from the development of a novel bioassay-guided screening platform for immunomodulatory compounds from an in-house MNPs library, we report the identification of the alkaloid lepadin A as a new model compound for immune-based anticancer activity with characteristics that suggest a possible mechanism as Immunogenic Cell Death inducer. The work describes the molecular-based bioprospecting in the Gulf of Naples together with the bioassay-guided fractionation, the chemical characterization of the alkaloid, and the biological activity in mouse dendritic cells (D1).

Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials.

BACKGROUND: The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce. OBJECTIVE: The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer. DATA SOURCES: A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words. STUDY SELECTION: Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. INTERVENTION(S): This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer. MAIN OUTCOME MEASURES: Primary outcomes were oncological parameters. RESULTS: Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group. LIMITATIONS: There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique. CONCLUSIONS: Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Bioactivity Screening of Antarctic Sponges Reveals Anticancer Activity and Potential Cell Death via Ferroptosis by Mycalols.

Sponges are known to produce a series of compounds with bioactivities useful for human health. This study was conducted on four sponges collected in the framework of the XXXIV Italian National Antarctic Research Program (PNRA) in November-December 2018, i.e., Mycale (Oxymycale) acerata, Haliclona (Rhizoniera) dancoi, Hemimycale topsenti, and Hemigellius pilosus. Sponge extracts were fractioned and tested against hepatocellular carcinoma (HepG2), lung carcinoma (A549), and melanoma cells (A2058), in order to screen for antiproliferative or cytotoxic activity. Two different chemical classes of compounds, belonging to mycalols and suberitenones, were identified in the active fractions. Mycalols were the most active compounds, and their mechanism of action was also investigated at the gene and protein levels in HepG2 cells. Of the differentially expressed genes, ULK1 and GALNT5 were the most down-regulated genes, while MAPK8 was one of the most up-regulated genes. These genes were previously associated with ferroptosis, a programmed cell death triggered by iron-dependent lipid peroxidation, confirmed at the protein level by the down-regulation of GPX4, a key regulator of ferroptosis, and the up-regulation of NCOA4, involved in iron homeostasis. These data suggest, for the first time, that mycalols act by triggering ferroptosis in HepG2 cells.

Drain Amylase Levels in the Early Diagnosis of Gastric Leak after Laparoscopic Sleeve Gastrectomy.

OBJECTIVES: Laparoscopic sleeve gastrectomy is gaining popularity as a bariatric option. Gastric leak is the most dreaded septic complication after this procedure. This study investigated levels of drain amylase that could be useful for predicting gastric leak before its clinical presentation. SUBJECTS AND METHODS: This prospective observational study was carried out in 167 patients who underwent sleeve gastrectomy for morbid obesity between February 2014 and March 2020. Measurement of drain amylase levels (DALs) was adapted as a routine procedure. The results of the receiver operative characteristic (ROC) curve analysis revealed an optimal drain amylase levels cutoff point of 814.18 IU/L. Consequently, the DALs were classified as DALs <814.18 or DALs ≥814.18 for all subsequent analyses. RESULTS: Gastric leak occurred in 6 patients. Drain amylase levels of 167 patients were tested. The mean value for patients without leak was 71.13 ± 72.11 IU/L; for patients with leak, it was 4,687 ± 6,670 IU/L (p < 0.001). Using ROC curve analysis, the mean ± standard error of the area under the curve for DALs on postoperative day 1 was 0.9927 ± 0.0075, CI = 0.978-1.00, and a cutoff level at 814.18 IU/L for predicting gastric leak achieved 83.33% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value 99.38%. All patients with a leak, but one, had a drain amylase level >814.18 IU/L. CONCLUSION: The determination of drain amylase levels after sleeve gastrectomy is a significant indicator of gastric leak with high sensitivity and specificity.

Haemobilia secondary to a cystic artery pseudoaneurysm as complication of VLC.

INTRODUCTION: The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare. CASE REPORT: Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition. CONCLUSION: Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels' injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak.

SETTING: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes. OBJECTIVES: This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG. PATIENTS AND METHODS: This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR). RESULTS: GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance. CONCLUSIONS: Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Partial agenesis of dorsal pancreas. Report of two cases.

INTRODUCTION: Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly resulting in missing corpus and cauda of the pancreas. The possibility of finding this disorder is increasing with the use of advanced radiological techniques like CT scan or MRI. PRESENTATION OF CASE: We reported 2 cases of a partial ADP as radiological finding: the first one was a 79-year-old asymptomatic patient who presented to perform a CT staging scan for bladder tumor, while the second case was a 73-year-old patient with obstructive jaundice and with suspected common bile duct calculi. In the second patient US, CT scan and MRI were performed, and after that also an ERCP was scheduled. DISCUSSION: The prevalence of agenesis of the dorsal pancreas is not exactly known; in the literature, only 50 cases have been reported. Its cause and pathogenesis are not fully understood. Some patients experience no symptoms, while others may develop hyperglycemia, diabetes mellitus, bile duct obstruction, abdominal pain, pancreatitis, or other conditions. CONCLUSION: Considering that dorsal agenesis is sporadically found, often do not have related symptoms and it does not require a specific treatment, whether further examinations are needed to determine the type of agenesis remains questioned.

Branch Duct - IPMN and PanIN, in IgG4-Autoimmune pancreatitis: A case report.

The presence of pancreatic lesions in patients with autoimmune pancreatitis requires histological diagnosis (percutaneous or endoscopic biopsy) to exclude malignancy. A nonspecific histology after endoscopic or percutaneous biopsy of a pancreatic lesion may require surgical excision and definite histology.

A case of segmental hepatic necrosis complicating oxaliplatin and capecitabine chemotherapy A case report and review of the literature.

Chemotherapy is associated with different patterns of histopathological changes of the non-tumor-bearing liver. Hepatic infarction represents a relatively rare condition; the prevalence in several series of consecutive autopsies is 1.1%. To the best of our knowledge, no cases of liver infarction secondary to chemotherapy have been reported to date. We report a case of segmental hepatic infarction following the adjuvant chemotherapy with Oxaliplatin and Capecitabine in a patient who had undergone total gastrectomy and distal esophagectomy for gastric cancer. Liver infarction is usually managed by conservative therapy; interventional procedures such as percutaneous imaging-guided drainage or surgical evacuation should be reserved in cases where septic complications occur, with development of a hepatic abscess from the necrotic area. It is important to avoid misdiagnoses with liver metastases in order to define the most appropriate clinical management strategy. KEY WORDS: Adjuvant chemotherapy, Gastric cancer, Liver infarction, Hepatic necrosis.

A rare case of cardiac tamponade masquerading as acute abdomen.

INTRODUCTION: Acute abdomen is any acute abdominal condition requiring a quick response. The incidence varies according to age and disease aetiology. The abdominal discomfort associated with extra-abdominal pathophysiology and thoracic conditions could mimic acute abdomen. In this case we report a rare case of a young patient with cardiac tamponade masquerading as acute abdomen. PRESENTATION OF CASE: A 25-years-old African man presented to the Emergency Department with abdominal pain. An EKG was performed, which revealed sinus tachycardia, with electrical alternans and borderline reduced voltage. At the time of the admission to our unit, he had a clinical worsening and a CT scan of abdomen was performed, which demonstrated hepatomegaly, abundant pericardial effusion and thin right pleural effusion at the lung bases. An echocardiogram confirmed a circumferential pericardial effusion with initial collapse of the right ventricular free wall. It was decided to immediately transport the patient to the Cardiosurgery Unit of another hospital to undergo pericardiocentesis. DISCUSSION: Our experience with this case underlines the important point that patients with a large pericardial effusion may present with the clinical features of acute abdomen and peritonitis. Abdominal pain was the primary symptom that prompted this patient to seek medical attention. CONCLUSION: Acute abdomen is any acute abdominal condition requiring a rapid, often surgical, treatment. Cardiac tamponade is a medical emergency. The differential diagnosis could be kept in mind by any emergency physician, surgeon and anaesthesiologist, because an incorrect diagnosis and therefore an incorrect treatment or a delay in pericardial evacuation can be life-threatening.

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis.

BACKGROUND: Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA. METHODS: Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis. RESULTS: TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis. CONCLUSIONS: TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.

Hyaluronan Metabolism is Associated with DNA Repair Genes in Breast and Colorectal Cancer. Screening of Potential Progression Markers Using qPCR.

In this work, we compared mRNA levels of Hyaluronan (HA) metabolism members and BRCA genes, known to be involved in the tumoral process, between tumor and non-tumor adjacent tissue and its correlation with previously proposed biomarkers (ER, PR, HER2 and KI67) in order to assess their value as a progression biomarkers. We show alteration in HA metabolism in colorectal but not breast cancer. However, we found a decrease in Hyaluronidase 1 HYAL1 levels in the breast but not colorectal cancer. We also show lower HA levels in tumor compared with normal tissue that could indicate a possible influence of tumor on its surrounding "normal" tissue. In both breast and colorectal cancer, CD44 and BRCA2 showed a strong positive correlation. Besides, our results show first indicators that qPCR of the analyzed genes could be used as an easy and low cost procedure for the evaluation of molecular markers we propose here.