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BACKGROUND: The Italian Research Group for Gastric Cancer supports the practice of follow-up after radical surgery for gastric cancer. METHODS: This multicenter, retrospective study (1998-2009) included patients with T1-4N0-3M0 gastric cancer who had undergone D2 gastrectomy and lymphadenectomy, with at least 15 lymph nodes examined, and who had developed recurrent disease. Timing and site of recurrence were correlated to the actual scheduled follow-up timing and modalities. RESULTS: From eight centers, 814 patients with recurrent cancer and over 1,754 (46.4 %) patients undergoing gastrectomy were investigated (median follow-up 31 months). The most frequent sites of recurrence were local/regional lymph nodes (35.4 %), liver (24.3 %), peritoneum (30.3 %), lung (10.4 %) and intraluminal (7.5 %). Ninety-four percent of the recurrences were diagnosed within 2 years and 98 % within 3 years. Thoracoabdominal computed tomography (CT) scan and (18)F-fluoro-2-deoxy-D-glucose positron emission tomography (18-FDG-PET) detected more than 90 % of recurrences, abdominal ultrasound detected 70 % and tumor markers detected 40 %, while <10 % were identified by physical examination, chest X-ray, and upper gastrointestinal endoscopy. Twenty-six percent of patients with recurrence were treated, but only 3.2 % were treated with potentially radical intent. CONCLUSION: Oncological follow-up after radical surgery for gastric cancer should be focused in the first 3 years, and based mainly on thoracoabdominal CT scan and 18-FDG-PET.
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Gastrectomía , Neoplasias Hepáticas/diagnóstico , Neoplasias Pulmonares/diagnóstico , Escisión del Ganglio Linfático , Recurrencia Local de Neoplasia/diagnóstico , Neoplasias Peritoneales/diagnóstico , Neoplasias Gástricas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Endoscopía Gastrointestinal , Femenino , Fluorodesoxiglucosa F18 , Estudios de Seguimiento , Humanos , Italia , Neoplasias Hepáticas/secundario , Neoplasias Pulmonares/secundario , Metástasis Linfática , Masculino , Persona de Mediana Edad , Neoplasias Peritoneales/secundario , Examen Físico , Tomografía de Emisión de Positrones , Radiofármacos , Estudios Retrospectivos , Estómago , Tasa de Supervivencia , Factores de Tiempo , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
BACKGROUND & AIMS: The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤3 cm and compensated cirrhosis. METHODS: The study involved 544 Child-Pugh A cirrhotic patients (246 in the resection group and 298 in the radiofrequency group) observed in 15 Italian centers. Overall survival and tumor recurrence rates were analyzed using the Kaplan Meier method before and after propensity score matching. Cox regression models were used to identify factors associated with overall survival and tumor recurrence. RESULTS: Two cases of perioperative mortality were observed in the resection group and the rate of major complications was 4.5% in the resection group and 2.0% in the radiofrequency group (p=0.101). Four-year overall survival rates were 74.4% in the resection group and 66.2% in the radiofrequency group (p=0.353). Four-year cumulative HCC recurrence rates were 56% in the resection group and 57.1% in the radiofrequency group (p=0.765). Local tumor progression was detected in 20.5% of ablated patients and in one resected patient (p<0.001). After propensity score matching, both survival and tumor recurrence were still not significantly different although a trend towards lower recurrence was observed in resected patients. Older age and higher alpha-fetoprotein levels were independent predictors of poor overall survival while older age and higher alanine-aminotransferase levels resulted to be independent factors associated with higher recurrence rate. CONCLUSIONS: In spite of a higher rate of local tumor progression, radiofrequency ablation can provide results comparable to liver resection in the treatment of single hepatocellular carcinoma ≤3 cm occurring in compensated cirrhosis.
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Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Ablación por Catéter , Recolección de Datos , Femenino , Hepatectomía , Humanos , Italia/epidemiología , Estimación de Kaplan-Meier , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Isolated dissection of visceral arteries without associated aortic pathology is very rare. Risk factors, etiology, and natural history of this pathology continue to be unclear, and the guidelines for clinical management remain to be defined. We present a case not described previously, with sequential dissections of the celiac trunk, superior mesenteric artery, and renal arteries without aortic involvement. The patient presented with severe back thoracic and abdominal pain and without evidence of peritonitis. An abdominal angio-CT scan showed dissection of the superior mesenteric artery (SMA), with partial thrombosis of the false lumen and subsequent stenosis of around 60%. Conservative treatment with anticoagulants seemed to be appropriate in the beginning, because the patient became asymptomatic spontaneously within a few hours and angio-CT showed dissection but no ischemic lesions. On day 10 after onset, however, he again indicated severe back thoracic and abdominal pain. Emergent CT was performed. The prior SMA dissection appeared to be worse due to increased size of the false lumen, followed by SMA stenosis (about 75â80%). In addition, dissection of the celiac artery and both renal arteries could be seen. The patient underwent angiography and stenting of the main trunk of the SMA, with good clinical and radiologic outcome. Double oral antiplatelet therapy was then introduced. An angio-MRI scan 6 months later showed stability of the multiple dissections.
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Disección Aórtica/terapia , Fibrinolíticos/uso terapéutico , Arterias Mesentéricas , Terapia Trombolítica/métodos , Disección Aórtica/diagnóstico , Estudios de Seguimiento , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
Hepatocellular carcinoma (HCC) is a very angiogenic and malignant cancer. Conventional chemotherapy is poorly effective because of the abnormal structural organization of HCC-infiltrating vessels. In previous work, we demonstrated that HCC angiogenesis is driven by transforming growth factor beta-1(TGF-ß1)/CD105 axis, stimulating liver-derived microvascular endothelial cells (Ld-MECs) migration. As TGF-ß1 also affects mural cells (MCs) recruitment and maturation, we asked whether it may contribute to HCC-induced vascular abnormalities. HCC and adjacent non-neoplastic liver (nNL) biopsies obtained from 12 patients were analyzed by immunohistochemistry for angiogenic markers CD105, TGF-ß1, CD44 and vascular endothelial growth factor-a (VEGFa) and for MC markers NG2, α-smooth muscle actin (αSMA) and neural cell adhesion molecule (NCAM). The same markers were also investigated by immunocytochemistry on cultured HCC-derived stromal cells (HCC-StCs) and nNL-derived StCs (nNL-StCs) isolated from the same liver biopsies. Angiogenic factors released by StCs were analyzed by ELISA and the interaction between StCs and Ld-MECs by adhesion assay. Compared with nNL, HCC biopsies showed increased angiogenic markers and αSMA that was localized in vessels. By contrast, NG2 and NCAM were substantially localized in tumor cells but absent in vessels and stroma. Cultured HCC-StCs showed less expression of NG2, αSMA and NCAM. They also demonstrated a lower capacity to release angiogenic factors and adhered on Ld-MECs. HCC-StCs and nNL-StCs treated with TGF-ß1 or with of HepG2 (a human hepatoma cell line) derived conditioned medium (CM), down-modulated NCAM expression, whereas anti-NCAM antibodies significantly reduced the adhesion of StCs to Ld-MECs. By further blocking TGF-ß1 with anti-TGF-ß1 antibodies or with Ly-364947 (a specific inhibitor TGF-ß1-receptor) adhesion to Ld-MECs and NCAM expression respectively was partially restored. TGF-ß1 contributes to HCC-induced vascular alterations by affecting the interaction between HCC-StCs and Ld-MECs through a down-modulation of NCAM expression.
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Carcinoma Hepatocelular/metabolismo , Regulación hacia Abajo , Neoplasias Hepáticas/metabolismo , Microvasos/anomalías , Moléculas de Adhesión de Célula Nerviosa/fisiología , Factor de Crecimiento Transformador beta1/fisiología , Biomarcadores/metabolismo , Carcinoma Hepatocelular/irrigación sanguínea , Carcinoma Hepatocelular/patología , Línea Celular Tumoral , Ensayo de Inmunoadsorción Enzimática , Citometría de Flujo , Humanos , Inmunohistoquímica , Neoplasias Hepáticas/irrigación sanguínea , Neoplasias Hepáticas/patología , Neovascularización PatológicaRESUMEN
BACKGROUND: Malignancy in intraductal papillary mucinous neoplasms (IPMN) of the pancreas may be predicted on the basis of a number of clinical and radiologic features, which have raised sensitivity but result in a specificity as low as 20-50%. We sought to confirm the additional value of (18)F-18-fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) in diagnostic accuracy of imaging-based IPMN malignancy assessment. METHODS: This prospective uncontrolled case series contained 44 patients with IPMN undergoing comprehensive diagnostic evaluation, including magnetic resonance cholangiopancreatography and (18)FDG-PET. Average follow-up time was 39.3 months (range 3-97 months). Diagnostic performance regarding the diagnosis of malignancy was evaluated for the classic preoperative assessment, including clinical signs, CA 19-9, imaging (computed tomography and magnetic resonance cholangiopancreatography), and International Consensus Guidelines criteria, as well as (18)FDG-PET scan. RESULTS: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 100, 22, 32, 100, and 43%, and 83, 100, 100, 94, and 96%, respectively, for comprehensive assessment without and with (18)FDG-PET [maximum standardized uptake value (SUV(max)) cutoff of 2.5 MBq]. Elevated CA 19-9 values and positive PET scan were the only independent prognostic factors for malignancy (odds ratio 2.11, 95% confidence interval 1.15-2.74 and 5.49, 95% confidence interval 3.98-21.44, respectively). CONCLUSIONS: (18)FDG-PET is useful for detection of malignancy in IPMN, improving the differential diagnosis with benign cases by functional data. The choice of SUV(max) cutoff should maximize specificity.
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Adenocarcinoma Mucinoso/diagnóstico por imagen , Adenocarcinoma Papilar/diagnóstico por imagen , Carcinoma Ductal Pancreático/diagnóstico por imagen , Neoplasias Pancreáticas/diagnóstico por imagen , Tomografía de Emisión de Positrones , Adulto , Anciano , Anciano de 80 o más Años , Antígeno CA-19-9/sangre , Intervalos de Confianza , Fluorodesoxiglucosa F18 , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , RadiofármacosRESUMEN
BACKGROUND: The literature does not support the choice between open and laparoscopic management of splenic artery aneurysms (SAA). METHODS: We designed a prospective, randomized comparison between open and laparoscopic surgery for SAA. Primary end points were types of surgical procedures performed and clinical outcomes. Analysis was developed on an intention-to-treat basis. RESULTS: Fourteen patients were allocated to laparotomy (group A) and 15 to laparoscopy (group B). Groups displayed similar patient- and aneurysm-related characteristics. The conversion rate to open surgery was 13.3 %. The type of surgical procedure performed on the splenic artery was similar in the two groups: aneurysmectomy with splenic artery ligature or direct anastomosis was performed in 51 % and 21 % of patients in group A and in 60 % and 20 % in group B, respectively. The splenectomy rate was similar (14 % vs. 20 %). Postoperative splenic infarction was observed in one case in each group. Laparoscopy was associated with shorter procedures (p = 0.0003) and lower morbidity (25 % vs. 64 %, p = 0.045). Major morbidity requiring interventional procedures and blood transfusion was observed only in group A. Laparoscopy was associated with quicker resumption of oral diet (p < 0.001), earlier drain removal (p = 0.046), and shorter hospital stay (p < 0.01). During a mean follow-up of 50 months, two patients in group A required hospital readmission. In group B, two patients developed a late thrombosis of arterial anastomoses. CONCLUSIONS: Our study demonstrates that laparoscopy permits multiple technical options, does not increase the splenectomy rate, and reduces postoperative complications. It confirms the supposed clinical benefits of laparoscopy when ablative procedures are required but laparoscopic anastomoses show poor long-term results.
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BACKGROUND: Cardiovascular complications, such as death, myocardial infarction, or heart failure, are the leading causes of morbidity and mortality in adult patients undergoing major noncardiac surgery. OBJECTIVE: To evaluate the effects of an accurate preoperative cardiac evaluation, together with optimized perioperative drug therapy, in reducing cardiovascular events in patients undergoing open aortic surgery for abdominal aneurysm. METHODS: Between January 2000 and December 2008, we considered all consecutive patients undergoing elective abdominal aortic open surgery at the Vascular Surgery Unit of the University of Study-Spedali Civili (Italy). Since January 2003, we have used an intensive cardiac preoperative evaluation: patients with at least one cardiac risk factor received a preoperative cardiac evaluation; all non-invasive and invasive tests were performed preoperatively when indicated by the consultant cardiologist, that also optimized the pharmacological perioperative therapy. The outcome of the 418 patients undergoing surgery between 2003 and 2008 was compared with those of the 204 patients in the previous triennium 2000 to 2002, when only patients with positive history for cardiac disease received a standard preoperative cardiological clinical or instrumental evaluation. RESULTS: Patients enrolled in the 2003 to 2008 interval were slightly older and with a higher prevalence of comorbidities compared with those observed in the previous triennium; furthermore, the number of noninvasive tests performed before surgery increased significantly. Nevertheless, the number of major cardiac perioperative complications decreased over time: particularly, in-hospital mortality rate was 0.9% in the latter period, compared with 3.4% in the years 2000 to 2002. Also, the long-term mortality was significantly reduced in patients operated on between 2003 and 2008 compared with those operated on in the previous triennium. CONCLUSION: These data suggest a significant benefit of an intensive cardiac preoperative evaluation in reducing the incidence of perioperative and postoperative cardiac morbidity and mortality.
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Aneurisma de la Aorta Abdominal/cirugía , Fármacos Cardiovasculares/uso terapéutico , Enfermedades Cardiovasculares/tratamiento farmacológico , Procedimientos Quirúrgicos Vasculares , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/mortalidad , Distribución de Chi-Cuadrado , Comorbilidad , Procedimientos Quirúrgicos Electivos , Femenino , Pruebas de Función Cardíaca , Humanos , Italia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Cuidados Preoperatorios , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: The ergotamine tartrate associated with certain categories of drugs can lead to critical ischemia of the extremities. Discontinuation of taking ergotamine is usually sufficient for the total regression of ischemia, but in some cases it could be necessary thrombolytic and anticoagulant therapy to avoid amputation. CASE REPORT: A woman of 62 years presented with a severe pain left forearm appeared 10 days ago, with a worsening trend. The same symptoms appeared after 5 days also in the right forearm. Physical examination showed the right arm slightly hypothermic, with radial reduced pulse in presence of reduced sensitivity. The left arm was frankly hypothermic, pulse less on radial and with an ulnar humeral reduced pulse, associated to a decreased sensitivity and motility.Clinical history shows a chronic headache for which the patient took a daily basis for years Cafergot suppository (equivalent to 3.2 mg of ergotamine).From about ten days had begun therapy with itraconazole for vaginal candidiasis. The Color-Doppler ultrasound shown arterial thrombosis of the upper limbs (humeral and radial bilateral), with minimal residual flow to the right and no signal on the humeral and radial left artery. RESULTS: Angiography revealed progressive reduction in size of the axillary artery and right humeral artery stenosis with right segmental occlusions and multiple hypertrophic collateral circulations at the elbow joint. At the level of the right forearm was recognizable only the radial artery, decreased in size. Does not recognize the ulnar, interosseous artery was thin. To the left showed progressive reduction in size of the distal subclavian and humeral artery, determined by multiple segmental steno-occlusion with collateral vessels serving only a thin hypotrophic interosseous artery.Arteriographic findings were compatible with systemic drug-induced disease. The immediate implementation of thrombolysis, continued for 26 hours, with heparin in continuous intravenous infusion and subsequent anticoagulant therapy allowed the gradual disappearance of the symptoms with the reappearance of peripheral pulses. CONCLUSION: Angiography showed regression of vasospasm and the resumption of flow in distal vessels. The patient had regained sensitivity and motility in the upper limbs and bilaterally radial and ulnar were present.
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BACKGROUND: The presence of lymph node metastasis is one of the most important prognostic factors in patients with gastric carcinoma. Node-negative patients have a better outcome, nevertheless a subgroup of them experience disease recurrence. AIM: To analyze the clinicopathological characteristics of lymph node-negative advanced gastric carcinoma patients submitted to gastrectomy and D2 lymphadenectomy with a retrieved number of nodes greater than 15, after an actual follow-up of almost 5 years, and to evaluate outcome indicators. STUDY DESIGN: The records of 301 patients who underwent curative gastrectomy for gastric carcinoma and were adequately staged as N0 between 1992 and 2002 were retrospectively analyzed from the prospectively collected database of 7 centers participating to the Italian Research Group for Gastric Cancer. RESULTS: Disease-specific and disease-free survival after 3, 5, and 10 years were 90.4%, 86.1%, 75.9%, and 72.1%, 57.3%, 57.3%, respectively. Mortality was 1.7%. The factors associated with a better disease-free survival at univariate analysis were age <60, T2 tumors, distal location, intestinal histotype, and number of retrieved nodes >25; depth of infiltration and histotype were the only 2 independent predictors of 5-year recurrence-free survival at multivariate analysis. CONCLUSION: These parameters must be considered to stratify node-negative gastric cancer patients for an adjuvant treatment and follow-up scheduling. Survival was similar to that previously reported by Eastern Centers. Lymphadenectomy is suggested to be effective, and retrieval of more than 25 nodes may be warranted.
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Ganglios Linfáticos/patología , Neoplasias Gástricas/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Gastrectomía , Humanos , Italia/epidemiología , Escisión del Ganglio Linfático , Metástasis Linfática/patología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Neoplasias Gástricas/patologíaRESUMEN
BACKGROUND: Intraductal papillary mucinous neoplasms (IPMNs) are increasingly recognized entities, whose management remains sometimes controversial, due to the high rate of benign lesions and on the other side to the good survival after resection of malignant ones. METHODS: Retrospective analysis of a prospectively collected Western series of IPMN. RESULTS: Forty cases of IPMN were analysed (1992-2007). Most patients were symptomatic (72.5%); cholangio-MRI had the best diagnostic accuracy both for the tumour nature (83.3%) and for the presence of malignancy (57.1%). ERCP was done in 8 cases (20%), and the results were poor. Thirteen patients were treated by pancreatic resection and 27 were maintained in follow-up. Total pancreatectomy was performed in 46% of the cases; in situ and invasive carcinoma were recognized in 15.4% and 38.4% of the cases, respectively. The mean follow-up was 42 months (range 12-72). One only patients with nodal metastases died 16 months after the operation for disease progression, while 91.6% of the operated patients are disease free. Out of the 27 not resected patients, 2 out of 4 presenting a lesion at high risk for malignancy died, while the remaining are in good conditions and disease free, with a mean follow-up of 31 months. CONCLUSION: Therapeutic indication for IPMNs is mainly based upon radiological evaluation of the risk of malignancy. While the main duct tumours should be resected, preserving whenever possible a portion of the gland, the secondary ducts tumours may be maintained under observation, in absence of radiological elements of suspicion such as size larger than 3 cm, or a wall greater than 3 mm or nodules or papillae in the context of the cyst.
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Adenocarcinoma Mucinoso/patología , Carcinoma Ductal Pancreático/patología , Carcinoma Papilar/patología , Pancreatectomía , Neoplasias Pancreáticas/patología , Adenocarcinoma Mucinoso/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Ductal Pancreático/cirugía , Carcinoma Papilar/cirugía , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Neoplasias Pancreáticas/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
There is no doubt that postgraduate education and all "professional development activity" is in crisis, not only in our country but in all of Europe. The crisis is on one hand due to a lack of resources which has been evident for more than a decade, and on the other hand due to factors such as organization, culture, and education. Many of the chief medical disciplines such as internal medicine or general surgery, have been literally crushed and replaced by a myriad of subspecialties that have undermined the original unified character of the main disciplines 1. The teaching regulations in recent years have significantly limited students' opportunities to have direct, practical experience with surgery, which would allow them to develop their abilities and a true vocation , both crucial for a profession such as surgery which requires specific qualities and skills. Moreover the new regulations regarding admission to residency programs do not require candidates to make a definitive decision up front about what they want to specialize in, but rather leads them to accept any position among those still available after the candidates who are higher on the national rank-order list, get first pick of all specialties. General surgery is not among the specialties that are most popular in Italy and this appears to be true all over the world. It is therefore one of the few specialties that candidates with a low ranking are allowed to enter, even if they have no natural affinity for this discipline and no special desire to become a general surgeon. This is detrimental not only for healthcare as a whole and patients in particular, but for those doctors who would have selected surgery as their first choice , but cannot because they are too far down on the rank-order list. As a result a significant number of surgeons in training will leave during the five-year training period or after obtaining their diploma or will dedicate themselves to parasurgical activities or specific subspecialties, losing in a short time the broader skills of general surgery and emergency surgery. At the same time the universities has neither the organizational capacity, nor the resources to ensure that all these new subspecialties have the same degree of status and funding. Consequently, the training offered in each subspecialty is currently dependent not on an organic strategy but on factors such as problems with funding and administration, support from the medical industry, or, or even temporary appeal The crisis of training in emergency surgery is paradigmatic probably due to all of the above factors. The lack of foresight of the European institutions in charge has unfortunately had an completely negative influence on this discipline. While general surgery was imploding, the increase in the average age, the evolution of mechanization, the logistics of both work and pleasure, and the explosion of home automation, has dramatically increased the number of both trauma and non-trauma emergencies, increasing the need for professionals with specific cultural and technical skills. Coping with of surgical emergencies accounts for up to 50% of all surgical activity , but in Europe training in Emergency surgery, the only surgical discipline that still maintains the scientific, clinical, technical, and organizational knowledge and skills of general surgery, has been reduced to a bare minimum This affects morbidity and mortality rates, leading to a considerable increase in hospital costs 2. Our English colleagues put a spotlight on this problem some time ago, highlighting the professional and existential problems of surgeons who do not feel able to adequately manage any type of surgical emergency. They therefore demand on the one hand more effective technical training and on the other hand that emergency surgery be reserved only for specialists in the sector. But who will train them if residency programs in emergency surgery have been eliminated and have not been replaced, as they have, by training courses such as "Acute Care Surgery" Thanks to the attitude of national and continental institutions, the number and quality of training opportunities continues to decline Recently, the European Working Time Directive(EWTD) has been introduced, reducing by 50% the time that both tutors and residents could devote to professional activities (3), As a result, for some time now, public and private institutions, cultural and professional associations, trade union representatives, specialty organizations, scientific societies and whatever else, have been proposing and organizing events of all kinds: theoretical and practical courses, Masters programs, single-theme seminars, continuing medical education events, distance learning courses, Technical training live or on the simulator, Cadaver labs and so on, many of which have increased the financial burden on the individual doctor. The Royal College of Surgeons, calculated that the cost of completing the post-university requirements in surgery is today on average about £ 3360 (with a range of $2735 - 20780) compared to £2815 for internal medicine and £ 2215 for anesthesiology .This contributes significantly in increasing young doctors' loss of interest in this specialty. In particular, this applies to emergency surgery because of the poor quality of life , wage limitations, increased responsibilities, and legal disputes associated with this discipline4 . We feel that scientific societies must attempt to compensate for the deficits of institutional education by producing and supplying qualified products at a low price. In recent years various, chiefly Anglo-Saxon societies have proposed live courses on trauma surgery such as the ATOM and DSCT and practical theoretical courses on the first approach to patients requiring emergency care. AEMS has planned theoretical courses in emergency surgery aimed in particular at the acquisition of a European certificate of professional competence and qualification in emergency surgery and ESTES has done the same with regard to professional development in specific diagnostic and therapeutic emergency procedures 5. The Italian Society of Emergency Surgery and Trauma (SICUT), after having validated and proposed in Italy the best English-speaking products and having directly imported the DSCT, began its own production of residential events and dedicated education proposals addressed in particular to the young surgeons. The current symposium consists of a series of short presentations of the various training initiatives for the professional development of emergency surgical care staff that the SICUT has organized in the last few years . This is a series of educational and training events of different kinds, many of which are produced in partnership with other organizations, dedicated to surgeons willing to implement or renew their knowledge and technical skills.
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Cirugía General/educación , ItaliaRESUMEN
The effect of insulin on the vasoconstriction induced by norepinephrine is at present controversial. We have previously demonstrated that high-concentration insulin may induce an increased reactivity to norepinephrine in mesenteric small resistance arteries of spontaneously hypertensive rats. The aim of the present study was to evaluate the effects of low- and high-concentration insulin on the concentration-response curves to norepinephrine and acetylcholine in subcutaneous small resistance arteries of hypertensive and diabetic patients. Twelve normotensive subjects (NT), 11 patients with essential hypertension (EH), 8 patients with non-insulin-dependent diabetes mellitus (NIDDM), and 8 patients with both EH and NIDDM (EH + NIDDM) were included in the study. Subcutaneous small resistance arteries were dissected and mounted on an isometric myograph. Concentration-response curves to norepinephrine (from 10(-8) to 10(-5) mol/l) and acetylcholine (from 10(-9) to 10(-5) mol/l) were performed in the presence or absence of insulin 715 pmol/l (low concentration) and 715 nmol/l (high concentration). A significant reduction in the contractile response to norepinephrine was observed in NT after preincubation of the vessels with both low- and high-concentration insulin. No reduction was observed in NIDDM and EH + NIDDM, while a significant decrease was obtained in EH with high-concentration insulin. Moreover, a significant difference in reduction in contractile response at maximal concentration of norepinephrine in the presence of low-concentration insulin was observed in NT compared to EH (p = 0.03), NIDDM (p = 0.02), and EH + NIDDM (p = 0.05), whereas no difference was observed with high-concentration insulin. No differences in the concentration-response curves to acetylcholine before or after precontraction with either low- or high-concentration insulin were observed in any group. In conclusion, insulin at low (physiological) concentrations seems to induce a decreased reactivity to norepinephrine in subcutaneous small resistance arteries of NT, but this effect was lost in EH, NIDDM and EH + NIDDM. This effect does not seem to involve acetylcholine-stimulated nitric oxide release.
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Diabetes Mellitus Tipo 2/fisiopatología , Endotelio Vascular/fisiopatología , Hipertensión/fisiopatología , Insulina/metabolismo , Músculo Liso Vascular/fisiopatología , Tejido Subcutáneo/irrigación sanguínea , Vasoconstricción , Vasodilatación , Acetilcolina/farmacología , Adulto , Anciano , Arterias/metabolismo , Arterias/fisiopatología , Diabetes Mellitus Tipo 2/metabolismo , Relación Dosis-Respuesta a Droga , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/metabolismo , Femenino , Humanos , Hipertensión/metabolismo , Resistencia a la Insulina , Masculino , Persona de Mediana Edad , Músculo Liso Vascular/efectos de los fármacos , Músculo Liso Vascular/metabolismo , Norepinefrina/farmacología , Vasoconstricción/efectos de los fármacos , Vasoconstrictores/farmacología , Vasodilatación/efectos de los fármacos , Vasodilatadores/farmacologíaRESUMEN
Major hepatic resection in cirrhotic patients is associated with impaired liver regeneration and failure, leading to high peri-operative mortality. In this work, the causes of defective regeneration in cirrhotic liver and the utility of IL-6 treatment were investigated in an experimental model combining cirrhosis and partial hepatectomy in the rat. Relative to normal controls, decompensated cirrhotic animals showed decreased survival, while compensated cirrhotic animals showed similar survival but reduced hepatic DNA synthesis and newly regenerated liver mass amount. Defective liver regeneration was associated with a decrease in STAT3 and NF-kB activation, consistent with an increased accumulation of their respective inhibitors PIAS3 and IkBalpha, and with a decreased induction of Bcl-xL. Treatment with recombinant IL-6 enhanced survival of decompensated cirrhotic animals, while it did not affect survival of compensated cirrhotic animals but sustained liver regeneration, by restoring STAT3 and NF-kB activation and Bcl-xL induction to the levels found in normal controls. The pro-growth effects exerted by IL-6 treatment in cirrhotic liver were attained also at low, pharmacologically acceptable doses. In conclusion, our results suggest that IL-6 treatment may be therapeutic in major resection of cirrhotic liver.
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Interleucina-6/farmacología , Cirrosis Hepática Experimental/fisiopatología , Regeneración Hepática/efectos de los fármacos , Proteínas Recombinantes/farmacología , Animales , Hepatectomía , Hepatocitos/fisiología , Humanos , Proteínas I-kappa B/metabolismo , Cirrosis Hepática Experimental/inducido químicamente , Cirrosis Hepática Experimental/cirugía , Masculino , Chaperonas Moleculares/metabolismo , Inhibidor NF-kappaB alfa , FN-kappa B/metabolismo , Proteínas Inhibidoras de STAT Activados/metabolismo , Ratas , Ratas Sprague-Dawley , Receptores de Interleucina-6/metabolismo , Factor de Transcripción STAT3/metabolismo , Transducción de Señal , Proteína bcl-X/metabolismoRESUMEN
Severe secondary peritonitis is diagnosed in only 20-30% of all patients, but studies to date have persisted in using a standard fixed duration of antibiotic therapy. This prospective, double-blind, multicenter, randomized clinical study compared the clinical and bacteriological efficacy and tolerability of ertapenem (1 g/day) 3 days (group I) vs >or=5 days (group II) in 111 patients with localized peritonitis (appendicitis vs non-appendicitis) of mild to moderate severity, requiring surgical intervention. In evaluable patients, the clinical response as primary efficacy outcome were assessed at the test-of-cure 2 and 4 weeks after discontinuation of antibacterial therapy. Ninety patients were evaluable. In groups I and II, 92.9 and 89.6% of patients were cured, respectively; 95.3% in group I and 93.7% in group II showed eradication. These differences were not statistically significant. The most frequent bacteria recovered were Escherichia coli and Bacteroides fragilis. A wound infection developed in seven patients (7.7%) and an intraabdominal infection in one patient (1.1%). There was a low frequency of drug-related clinical or laboratory adverse effects in both groups. Our study demonstrated that, in patients with localized community-acquired intraabdominal infection, a 3-day course of ertapenem had the same clinical and bacteriological efficacy as a standard duration.
Asunto(s)
Antibacterianos/administración & dosificación , Peritonitis/tratamiento farmacológico , beta-Lactamas/administración & dosificación , APACHE , Apendicitis/complicaciones , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/microbiología , Método Doble Ciego , Ertapenem , Humanos , Peritonitis/etiología , Peritonitis/microbiología , Estudios Prospectivos , Infección de la Herida Quirúrgica/epidemiologíaRESUMEN
BACKGROUND: Laparoscopic adrenalectomy for pheochromocytoma remains subject of debate, owing to the systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors. METHODS: A prospective randomized study was conducted (2000-2006), evaluating cardiovascular instability during open (n = 9, group A) or laparoscopic (n = 13, group B) adrenalectomy for pheochromocytoma. Haemodynamic parameters were recorded by invasive monitoring. RESULTS: Haemodynamic instability was observed in 3/9 (group A) and 6/13 patients (group B), with a mean of 1.8 and 2.2 hypertensive peaks per patient (p = n.s.). Blood loss (164 +/- 94 cc versus 48 +/- 36 cc, p < 0.05) and operative time (180 +/- 40 versus 158 +/- 45 min, p = n.s.) favored laparoscopic procedures. Postoperative morbidity and mortality were nil. Hospital stay was shorter in group B (p < 0.05). Long-term follow-up was always normal. CONCLUSIONS: Laparoscopic approach for pheochromocytoma can be as safe as open surgery; intraoperative haemodynamic instability, although usually controlled with success, remains a source of concern.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía/métodos , Laparoscopía/métodos , Laparotomía/métodos , Feocromocitoma/cirugía , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/fisiopatología , Adulto , Anciano , Presión Sanguínea/fisiología , Dióxido de Carbono/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Feocromocitoma/diagnóstico , Feocromocitoma/fisiopatología , Neumoperitoneo Artificial/métodos , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Structural alterations in the microcirculation may be considered an important mechanism of organ damage. An increased tunica media to internal lumen ratio of subcutaneous small-resistance arteries (M:L) may predict the development of cardiovascular events in a high-risk population. However, it is not known whether structural alterations of small arteries may also predict major cardiovascular events. METHODS: Three hundred three subjects were included in the present study. There were 65 normotensive subjects, 111 patients with essential hypertension (33% of them with diabetes mellitus), 109 patients with secondary forms of hypertension, and 18 normotensive diabetic patients. Small-resistance arteries were dissected from subcutaneous fat biopsies and mounted on an isometric myograph, and the M:L was measured. Subjects were reevaluated after an average follow-up time of 6.9 years to assess the occurrence of cardio-cerebrovascular events. RESULTS: Eleven subjects died of a fatal cardio-cerebrovascular event (FCE), 14 had a major, nonfatal cardiovascular event (stroke or myocardial infarction) (SMI), 23 had a minor cardiovascular event (MCE), and 255 had no cardiovascular event (NCE). A significant difference was observed in M:L and in event-free survival between patients with FCEs+SMIs+MCEs and those with NCE and between patients with FCEs+SMIs and those with NCE. Similar results were obtained by restricting the analysis to patients with essential hypertension. CONCLUSIONS: Structural alterations of small-resistance arteries may predict FCE and SMI. The prognostic role of small-resistance artery structure also applies to medium-risk patients with essential hypertension, at least when MCEs are included in the analysis.
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Muerte Súbita/etiología , Hipertensión/fisiopatología , Microcirculación/fisiología , Infarto del Miocardio/etiología , Piel/irrigación sanguínea , Accidente Cerebrovascular/etiología , Resistencia Vascular/fisiología , Electromiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Túnica Media/fisiopatologíaRESUMEN
AIM OF THE STUDY: Perioperative and 10 years follow-up risk factors for 1111 consecutive open AAA repairs were statistically analyzed (X2-test and Log-rank test methods for univariate analysis, and logistic regression model and Cox proportional-hazard model for multivariate analysis). Overall operative mortality rate was 2.7%, and significant risk factors were: 1) univariate analysis: Age (>70 years 3.9% vs 1.5% <70 years); CAD (4.3% vs 1.9% without CAD); PAD (4.7% vs 2.0%); III-IV ASA classes (3.8% vs 0% in I-II ASA classes); 2) multivariate analysis: only ASA classes. RESULTS: Long-term survival (42.3 +/- 32.6 months) was 93% and 88% at 3 and 5 years respectively, with 0.2% graft-related deaths, and significant risk factors were 1) univariate analysis: Age (92% and 84% at 3 and 5 years in patients aged >70 vs 94% and 91% <70 years); ASA classes (91% and 87% at 3 and 5 years in ASA III-IV vs 98% and 92% in ASA I-II); CAD (92% and dell'85% vs 94% and 90% without CAD); COPD (90% and 80% vs 95% and 92% without COPD); CRF (90% and 82%, vs 94% and 89% without CRF); suprarenal aortic cross-clamping for pararenal aneurysms (91% and 77% in pararenal AAA, vs 94 % and 90% in infrarenal AAA; 2) multivariate analysis: Age; ASA classes; pararenal aneurysms. There was a close relation between number (0-5) of risk factors in each patient and early and late complications. These data are very satisfactory overall, and even in high risk patients who are routinely considered for EVAR.
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Aneurisma de la Aorta Abdominal/mortalidad , Procedimientos Quirúrgicos Electivos/mortalidad , Anciano , Análisis de Varianza , Aneurisma de la Aorta Abdominal/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Masculino , Enfermedades Vasculares Periféricas/complicaciones , Complicaciones Posoperatorias/mortalidad , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Factores de RiesgoRESUMEN
CONTEXT AND OBJECTIVE: It has been previously demonstrated that aldosterone may possess a strong profibrotic action in vitro and in animal models of genetic or experimental hypertension. Our aim was to evaluate whether such a profibrotic action is present also in the human microcirculation. DESIGN AND PATIENTS: We investigated 13 patients with primary aldosteronism, seven patients with essential hypertension, and 10 normotensive controls. All subjects were submitted to a biopsy of gluteal sc fat tissue. Small resistance arteries were dissected and mounted on an isometric myograph, and the tunica media to internal lumen ratio was measured. MAIN OUTCOME MEASURES: The total collagen content within the tunica media was detected (Sirius red staining and image analysis), and collagen subtypes were evaluated using polarized light microscopy; under this condition thicker type I collagen fibers appear orange or red, whereas thinner type III collagen fibers are yellow or green. RESULTS: Tunica media to internal lumen ratio was significantly increased in primary aldosteronism and in essential hypertension compared with normotensive controls. Clinic blood pressure values were similar in primary aldosteronism and in essential hypertension, and greater than in normotensive controls. Normotensive controls had less total and type III collagen (3.23 +/- 0.58 and 1.60 +/- 0.22%, respectively) in respect to the two hypertensive groups (P < 0.001). Total collagen and type III vascular collagen were significantly greater in primary aldosteronism (total collagen, 8.17 +/- 1.38%; type III collagen, 6.06 +/- 0.74%; P < 0.05) than in essential hypertension (total collagen, 6.84 +/- 1.15%; type III collagen, 5.25 +/- 0.80%). CONCLUSIONS: Our results indicate that, in small resistance arteries of patients with primary aldosteronism, a pronounced fibrosis may be detected, even more evident than in blood-pressure-matched patients with essential hypertension.
Asunto(s)
Arterias/ultraestructura , Matriz Extracelular/ultraestructura , Hiperaldosteronismo/patología , Tejido Adiposo/irrigación sanguínea , Adulto , Colágeno/análisis , Colágeno Tipo III/análisis , Matriz Extracelular/química , Femenino , Humanos , Hiperaldosteronismo/metabolismo , Hipertensión/metabolismo , Hipertensión/patología , Masculino , Persona de Mediana Edad , Túnica Media/química , Túnica Media/ultraestructuraRESUMEN
OBJECTIVE: The presence of endothelial dysfunction in the coronary circulation or in the brachial artery has been found to be associated with a greater incidence of cardiovascular events. However, no data are presently available about the prognostic role of endothelial dysfunction in human small resistance arteries. DESIGN AND METHODS: Ninety subjects were included in the present study. They were: 10 normotensive subjects, 36 patients with essential hypertension, 10 patients with phaeochromocytoma, 11 patients with primary aldosteronism, 10 patients with renovascular hypertension, and 13 normotensive patients with non-insulin-dependent diabetes mellitus (NIDDM). All subjects were submitted to a biopsy of subcutaneous fat from the gluteal or the anterior abdominal region. Small resistance arteries were dissected and mounted on an isometric myograph, and the concentration-response curves to acetylcholine (from 10 to 10 mol/l) (endothelium-dependent vasodilatation) and sodium nitroprusside (from 10 to 10 mol/l) (endothelium-independent vasodilatation) after precontraction of the vessels with norepinephrine were evaluated. The subjects were re-evaluated (by clinical visits or telephone interviews) after an average follow-up time of 5.5 years. RESULTS: Twenty-nine subjects had a documented fatal or non-fatal cardiovascular event (5.87%/year). The endothelium-dependent vasodilatation in the subcutaneous small arteries was similar in subjects with or without cardiovascular events. Also, endothelium-independent vasodilatation to sodium nitroprusside was similar in the two groups. Similar results were obtained by subdividing patients in the different subgroups (essential hypertension, secondary hypertension, etc.). CONCLUSIONS: Our results indicate that endothelial dysfunction in the microcirculation does not predict cardiovascular events. It is possible that a prognostic role of endothelial dysfunction may be observed when other vascular districts prone to atherosclerosis are evaluated, or it might be detected only in patients at low to medium cardiovascular risk, in whom endothelial dysfunction is less advanced.
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Arterias/fisiopatología , Endotelio Vascular/fisiopatología , Hipertensión Renal/diagnóstico , Hipertensión/diagnóstico , Resistencia Vascular , Acetilcolina/farmacología , Anciano , Arterias/efectos de los fármacos , Arterias/patología , Biopsia , Estudios de Casos y Controles , Diabetes Mellitus Tipo 2/complicaciones , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Humanos , Hiperaldosteronismo/complicaciones , Hipertensión/complicaciones , Hipertensión/patología , Hipertensión/fisiopatología , Hipertensión Renal/complicaciones , Hipertensión Renal/patología , Hipertensión Renal/fisiopatología , Masculino , Persona de Mediana Edad , Miografía , Nitroprusiato/farmacología , Norepinefrina/farmacología , Feocromocitoma/complicaciones , Pronóstico , Grasa Subcutánea/irrigación sanguínea , Grasa Subcutánea/patología , Grasa Subcutánea/cirugía , Factores de Tiempo , Vasoconstrictores/farmacología , Vasodilatadores/farmacologíaRESUMEN
Importance: The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined. Objectives: To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging. Design, Setting, and Participants: Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers. The last follow-up was assessed in July 2014. Main Outcome and Measures: Differences in overall survival (OS) according to the LN status were analyzed. The OS results were defined as actual because all included patients completed a 5-year follow-up. Results: One-hundred seventy-five patients with 1133 retrieved LNs were analyzed. The mean (SD) age of the cohort was 63 (10) years, and 42.9% (75 of 175) were female. The median number of LNs examined per patient was 6.5. Forty percent (70 of 175) had LN metastasis. An LNR exceeding 0.20 was associated with significantly lower 5-year OS than an LNR of 0.20 or less (10.6% vs 24.4%; odds ratio, 2.434; 95% CI, 1.020-5.810; P = .04). On multivariable analysis, the LNR was the only independent prognostic factor for OS but was influenced by the total number of retrieved LNs. The LNR was greater than 0.20 in all patients (30 of 30) with 1 to 4 retrieved LNs and in 52.5% (21 of 40) of patients with at least 5 retrieved LNs. Five-year OS in patients with 1 to 5 retrieved LNs was significantly lower than that in those with 6 to 7 retrieved LNs and those with at least 8 retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). Five-year OS did not significantly improve when the number of retrieved LNs was greater than 6. These results were confirmed in a receiver operating characteristic curve analysis performed among N0R0 patients, in whom 5 retrieved LNs was the most accurate cutoff to predict 5-year actual OS (area under the curve, 0.624; P = .004). Conclusions and Relevance: An LNR exceeding 0.20 was the only independent prognostic factor for OS in N1 patients after liver resection for HC. However, the LNR was influenced by the total number of retrieved LNs, and removal of more than 5 LNs was the minimum number of LNs required for adequate staging.