Management of grade III-IV blunt liver traumas: a comparative, observational study.

AIM: The aim of the present study was to assess the impact of angiographic embolization in view of expanding indications for the conservative management of grade III-IV liver injuries. METHODS: Fifty adult patients with grade III-IV hepatic trauma were admitted to our Hepato-Biliary-Pancreatic Surgery and Level II Regional Trauma Center from 1993 to 2010 and retrospectively analyzed. Injury severity, management strategies and outcomes of patients admitted between 1993 and 2005 were analyzed and compared with those admitted between 2005 and 2010. Univariable and multivariable logistic models were fitted to investigate the differences between the two time windows studied, in particular with regard to morbidity, mortality, treatment and outcomes, the use of non-operative management and of angiographic embolization. RESULTS: At univariable analysis the majority of the patients treated after 2005 were more likely to have undergone arterial embolization, and less likely to have incurred morbidity, conversion to surgery, or to be admitted to the Intensive Care Unit after initial treatment (baseline category). At multivariable analysis the patients treated before 2005 were more likely to be older than 25 years to receive angiographic embolization and less likely to undergo conversion to surgery after failure of non-operative management. CONCLUSION: The criteria for the conservative treatment of blunt liver trauma is presently often based on hemodynamic stability in injured patients, but its successful management should, instead, be based also on early CT recognition of arterial bleeding and prompt use of angiographic embolization to control it.

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship.

AIM: This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care. METHOD: One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis. RESULTS: Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (ß = -0.30, P = 0.004, and ß = -0.42, P < 0.001). CONCLUSION: In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Cost-effectiveness analysis of postoperative surveillance protocols following radical surgery for colorectal cancer.

INTRODUCTION: Up to 30-50% of patients who undergo radical surgery for colorectal cancer (CRC) develop tumor relapse. The aim of this study was to assess various surveillance protocols utilized in a tertiary referral hospital in Northern Italy. METHODS: Data concerning 373 consecutive patients who underwent radical surgery for CRC between 1990 and 2006 and whose data had been entered into a prospective database were considered eligible for this study. The overall costs and the percentages of recurrence following the various surveillance protocols were calculated. RESULTS: One hundred two (27.35%) of the patients suffered a recurrence after a mean of 17.6 (95% CI 13.9-21.1) months. The combination of physical examination, colonoscopy, thorax-abdominal computed tomography (CT) scan, and serum carcinoembryonic antigen (CEA) dosage was found to be the most cost/effective one to monitor stages I and II colon cancer; while physical examination, rigid sigmoidoscopy, thorax-abdominal CT scan, and serum CEA dosage were found to be the most cost/effective surveillance to monitor stages III and IV of colon cancer and rectal cancer. CONCLUSIONS: Adherence to follow-up guidelines and early detection are vital factors affecting the curability of relapsed cancer in CRC patients who undergo surgery. The first five years after surgery was found to be the most risky period for recurrence. Cost/effectiveness analysis indicate that follow-up protocols should be tailored to the risk of recurrence with the aim of identifying relapse when the disease is at an asymptomatic, presumably more curable stage.

Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period.

AIM: This study quantified prospectively the amount of rectal wall removed during stapled haemorrhoidopexy and assessed its effect on ano-rectal function and health-related quality of life. METHOD: Thirty-three consecutive patients who underwent stapled haemorrhoidopexy for second- or third- degree haemorrhoids, or for failed medical treatment, in the Department of Surgery and Gastroenterological Sciences at the University of Padova were included. All patients were assessed preoperatively and postoperatively using a structured questionnaire to determine the number of defecations per week, incomplete defecations, time taken to defecate any difficulty in defecating, soiling, the use of drugs and continence. All patients were reassessed at 1 and 2 weeks and at 30 days after the procedure using the Cleveland Global Quality of Life (CGQL) questionnaire. All patients underwent preoperative and postoperative ano-rectal manometry at least 30 days after stapled haemorrhoidopexy. RESULTS: The median surface area of the resected rectal wall was 10.5 (range, 9-15) mm(2) and the median thickness was 3 (range, 2-4) mm. Muscle tissue was included in all specimens. The median thickness of the resected rectal wall correlated inversely with the rectal volume when the recto-anal inhibitory reflex (RAIR) was initiated during postoperative manometry (ρ = -0.50, P = 0.07). A significant, direct correlation was found between the surface area of the resected rectal wall and the rectal volume during postoperative manometry (ρ = 0.53, P = 0.08) and the use of analgesic drugs after 2 weeks (ρ = 0.63, P = 0.04). Significant correlations were found between being female and postoperative resting pressure (ρ = -0.74, P < 0.01), squeeze pressure (ρ = -0.64, P = 0.01) and maximum tolerated volume (ρ = -0.78, P < 0.01). CONCLUSION: Stapled haemorrhoidopexy is safe and effective. The thicker the resected rectal wall, the lower the volume of initiation of the RAIR.

A systematic review on advancement flaps for rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach.

AIM: Despite advances in the treatment of Crohn's disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD. METHOD: Medical databases from January 1983 to August 2008 were consulted for potentially relevant publications. All studies dealing with the RV fistula repair in CD with RAF or VAF were included. Two researchers worked independently on the study selection, quality assessment, data extraction and analysis phases of the study. Analyses were performed with Review Manager 2.0 software. RESULTS: Eleven observational studies were included with a total of 219 flap procedures for RV fistula. The primary fistula closure pooled rate was 54.2% (range 33.3-100%) after RAF and 69.4% (range 0-92.9%) after VAF (P = 0.13). Four studies were eligible for direct comparison between the two procedures. No clearly significant difference between RAF compared with VAF in terms of primary fistula closure rate, nor in terms of overall fistula closure rate, was apparent. The risk of recurrence after RAF compared with VAF seemed similar; in this case, only two studies were taken into consideration. CONCLUSIONS: Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.

Diverting loop ileostomy after restorative proctocolectomy: predictors of poor outcome and poor quality of life.

AIM: Diverting loop ileostomy is used to minimize the impact of anastomotic complication after restorative proctocolectomy (RPC). However, the ileostomy itself may have complications and therefore affect quality of life (QOL). The aim of this study was to analyse the predictors of complications of the ileostomy formation and closure and of the QOL of these patients. METHOD: Forty-four consecutive patients who underwent RPC were enrolled. Records of the ileostomy follow-up were retrieved from a prospectively collected database and QOL was assessed with the Stoma-QOL questionnaire. Ileostomy site coordinates were measured. Univariate and multivariate analysis were performed. RESULTS: In this series, three patients experienced peristomal herniae, two ileostomy stenosis, seven ileostomy retraction and fourteen peristomal dermatitis. Emergency surgery was the only predictor of parastomal hernia (P = 0.017). Stenosis correlated with the distance from the umbilicus (tau = 0.24, P = 0.021). Use of standard rod and retraction were independent predictors of peristomal dermatitis (P = 0.049 and P = 0.001). Stoma-QOL was directly correlated to the age of the patients and to the occurrence of parastomal hernia (P = 0.001 and P = 0.021, respectively). After stoma closure, two patients reported wound sepsis and seven suffered obstructive episodes. CONCLUSION: The predictors of negative outcome after construction of a diverting loop ileostomy after RPC were urgent surgery, use of standard rod, the distance of the stoma site from the umbilicus, parastomal herniae and the older age of patients.

Outcome of surgery for rectovaginal fistula due to Crohn's disease.

BACKGROUND: This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing. METHODS: Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment. RESULTS: Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients. CONCLUSION: Fistula closure was achieved in most patients, but more than one operation was often required.

Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients.

BACKGROUND: The distribution of lesions in the gastrointestinal tract in patients with sporadic telangiectasia is at present unknown. PATIENTS AND METHODS: 75 patients with sporadic telangiectasia underwent esophagogastroduodenoscopy (EGD), capsule endoscopy, and colonoscopy. Endoscopic diagnosis of telangiectasia and gastrointestinal bleeding were required for enrollment in the study. Hemorrhagic diathesis, co-morbidity, number of blood transfusions, and subsequent management were also noted. RESULTS: 35 of the patients presented with gastroduodenal vascular lesions, 51 with small-bowel lesions, and 28 with colonic lesions. 67 % of patients in whom EGD found telangiectasia also presented small-bowel vascular lesions at capsule endoscopy and 43 % colonic lesions at colonoscopy. 54 % percent of patients with positive colonoscopy also presented gastroduodenal lesions and 48 % small-bowel lesions. Patients with known duodenal lesions were more likely to have small-bowel lesions at capsule endoscopy (odds ratio [OR] 10.19, 95 % CI 2.1 - 49.33, P = 0.003). Patients with associated diseases, such as liver cirrhosis, chronic renal failure, or heart valvulopathy, presented more severe disease requiring blood transfusions (OR 6.37, 95 % CI 1.39 - 29.2, P = 0.015). The number of blood transfusions correlated with the number of sites affected ( R = 0.35, P = 0.002). The detection of new lesions at capsule endoscopy allowed new treatment in 46 % of patients. Mean follow-up was 18 months. CONCLUSIONS: Sporadic telangiectasia is a multifocal disease potentially involving the whole digestive tract. Patients with duodenal telangiectasia show a higher risk of jejunal or ileal lesions. Capsule endoscopy is a useful diagnostic tool for the detection of such small-bowel vascular lesions, indicating a more specific prognosis and treatment strategy.

Recurrent pleural effusion and pulmonary metastases from a cutaneous apocrine tumour of the axilla.

Sweat gland carcinomas are very rare and they are differentiated between tumours of apocrine or eccrine origin. The axilla is the most common site for apocrine gland carcinoma for its great abundance of these glands. There are no recommendations in literature regarding appropriate treatment schedules for apocrine gland carcimonas in advanced stages. We report a case of recurrent left pleural effusion in a 76-year old man with metastatic cutaneous apocrine tumour of the right axilla. We describe the clinical and histological features, with management options and a review of the relevant literature on apocrine gland carcinoma.

Should we routinely use DEBTACE for unresectable HCC? cTACE versus DEBTACE: a single-center survival analysis.

Conventional trans-arterial chemoembolization (cTACE) for intermediate stage hepatocellular carcinoma (HCC) achieves a partial response in up to 72% of patients and improves median survival. Drug-eluting-beads-TACE (DEBTACE) improves treatment efficacy and tolerance as compared to cTACE. Our aim was to retrospectively evaluate our experience in the treatment of intermediate/advanced HCC with cTACE versus DEBTACE. Overall survival (OS) was the first endpoint. We retrospectively considered our department register data between 2006 and 2012. A total of 82 non-surgical patients, who underwent cTACE or DEBTACE, with a minimum of 12 months follow-up, met the inclusion criteria. Patients received a standard chemotherapy dose (50 mg). Radiological response was evaluated by CT after 30 days and re-treatment was considered. Statistical analysis was performed with SPSS software. 54 patients received cTACE and 28 DEBTACE. In the DEBTACE group the median survival times was 22.7 months (CI 11.6-33.8), while in the cTACE group it was 21.8 months (CI 15.7-27.9). The survival analysis at log-rank (p = 0.708) and Wilcoxon (p = 0.661) tests demonstrated no differences between DEBTACE and cTACE. The probability of death in function of time was significantly associated only to the Child-Pugh score. A Child A score was shown to be protective instead of Child B (OR 0.583; IC 95% = 0.344-0.987). DEBTACE for treating HCC is comparable to cTACE in terms of effectiveness, but seems to be better tolerated. Both treatments can be performed in case of tumor recurrence without substantial increase in procedural complications and risk of liver failure. We do confirm that there are no differences between the two techniques in terms of survival and that it is mainly affected by the reserved liver function proper of each patient.

Effects of iron manipulation on trace elements level in a model of colitis in rats.

AIM: Trace elements (TE) metabolism is altered in inflammatory bowel diseases. TE (zinc and copper) are constituents of antioxidant enzymes. Iron is involved in the pathogenesis of chronic inflammation. The aim was to evaluate zinc and copper status and the effects of iron manipulation in experimental colitis. METHODS: Twenty-four male Sprague-Dawley rats were divided into four groups: standard diet, iron-deprived diet, iron-supplemented diet, and sham-treated controls. Macroscopic damage was scored. DNA adducts were measured in the colon. Liver and colonic concentration of TE were measured. RESULTS: Macroscopic damage was reduced in iron-deprived groups and increased in iron-supplemented rats. Damage to the DNA was reduced in iron-deprived groups and increased in iron-supplemented groups. Liver and colonic iron concentrations were reduced in iron-deprived and increased in iron-supplemented rats. Liver zinc concentration was reduced after supplementation whereas colonic levels were similar in controls and treated rats. Liver copper concentration was reduced in all the colitic groups except in the iron-supplemented group whereas colonic concentration was increased in iron-deprived rats. CONCLUSION: Iron deprivation diminishes the severity of DNBS colitis while supplementation worsens colitis. Zinc and copper status are modified by iron manipulation.

Characterisation of a Pasteurella multocida esterase gene which confers a hemolytic phenotype in Escherichia coli under anaerobic conditions.

Investigation of the hemolytic phenotype under anaerobic growth conditions of an avian Pasteurella multocida strain, PBA100, resulted in the identification and characterisation of a gene encoding an esterase enzyme, mesA, that conferred a hemolytic phenotype in Escherichia coli under anaerobic conditions. MesA appeared to be expressed and functional under anaerobic and aerobic conditions in both E. coli and P. multocida. A P. multocida mesA mutant was generated which resulted in the loss of acetyl esterase activity under anaerobic conditions. However, this mutation did not cause any attenuation of virulence for mice nor a detectable change to the anaerobic hemolytic phenotype of P. multocida. In E. coli MesA appeared to cause hemolysis indirectly by the induction of the latent E. coli K-12 cytolysin, sheA.

Immunity and vaccine development in Pasteurella multocida infections.

The role of LPS in immunity was studied using monoclonal antibodies (MAbs) and active immunisation experiments. A panel of six MAbs produced against Pasteurella multocida serotype B:2 reacted with the LPS of serotypes B:2 and B:5, but not with other serotypes. The MAbs could opsonise P. multocida for phagocytosis by mouse macrophages, but were not bactericidal in the presence of complement. They conferred only partial passive protection in mice. Similar results showing only partial protection were obtained when purified LPS was used to actively immunise mice prior to challenge, suggesting that LPS plays a partial role in immunity to infection. The aroA gene from P. multocida serotypes A:1 and A:3 was cloned and inactivated by insertion of a kanamycin resistance gene. The mutated gene was re-introduced onto the chromosome by allelic exchange. The resultant aroA mutants were highly attenuated in a mouse model system, with a 6-log decrease in ID50. Virulence could be restored by complementation with a functional aroA gene. Mice immunised with two doses of the live mutants were protected against lethal challenge with the homologous parental strain, but not against the heterologous strain. P. multocida A:1 and A:3 expressed unique proteins when grown in iron-restricted medium. Moreover, the outer membrane (OM) fractions of these cells contained novel proteins of 75 kDa, 85 kDa and 94 kDa molecular mass. Mice were immunised with OM fractions prepared from serotype A:3 grown in iron-restricted (OM Fe-) or iron-replete (OM Fe+) media. When low challenge doses were used, both immunogens protected mice against serotype A:3, but only the OM Fe- fraction protected mice against heterologous challenge with serotype A:1. When higher challenge doses were used, only partial protection was observed.

Candidate vaccine antigens and genes in Pasteurella multocida.

Pasteurella multocida is the causative agent of fowl cholera and other diseases of production animals. Isolates are classified into five groups based on capsular antigens and into 16 serotypes based on LPS antigens. Strains causing fowl cholera are most frequently designated A:1, A:3 or A:4. Whole cell bacterins can provide some degree of protection, but only against the homologous LPS serotype. There is good evidence that cross-protective antigens are expressed only under in vivo conditions. Empirically derived, live, attenuated vaccines can protect against heterologous serotypes, but because the basis for attenuation is undefined, reversion to virulence is not uncommon. Work in our laboratory is aimed at using a variety of approaches to identify potential protective antigens or virulence genes to be used as candidates for attenuating mutations or as the basis for vaccine antigen delivery systems. The gene encoding an outer membrane protein, Oma87, which is a homologue of the D15 protective antigen of Haemophilus influenzae, was cloned and sequenced. Rabbit antiserum prepared against recombinant Oma87 could passively protect mice against infection. Type 4 fimbriae form the basis of vaccines against ovine footrot and bovine keratoconjunctivitis. We have identified type 4 fimbriae on the surface of P. multocida, purified the fimbrial subunit protein, PtfA, and determined its N-terminal amino acid sequence. Subsequent cloning of the ptfA gene and its inactivation will now be used to assess the importance of type 4 fimbriae in virulence. There has long been anecdotal evidence for the importance of capsule in virulence, but unequivocal genetic evidence for such a role is lacking. We have cloned and characterised the capsule biosynthetic locus in P. multocida A:1 and identified four bex genes involved in capsule transport and genes encoding enzymes involved in the biosynthesis and transfer of the N-acetyl glucosamine and glucuronic acid components of the capsule. It has been suggested that the low concentration of available iron in vivo acts as an environmental cue for expression of cross-protective antigens. Accordingly, we have cloned and characterised the gene encoding transferrin binding protein, Tbpl, so that its role in immunity and virulence can be investigated. Although P. multocida is not normally considered haemolytic, we have observed haemolysis under anaerobic conditions. Standard library construction and screening resulted in the identification of the mesA gene which encodes an esterase enzyme resulting in a haemolytic phenotype under anaerobic conditions. Virulence studies with mesA- mutants were performed to assess its role in pathogenesis. Using a promoterless phoA gene vector system, the cloning of proteins homologous to known surface proteins of other species as well as proteins unique to P. multocida, allowing their potential as vaccine components to be assessed.

The type 4 fimbrial subunit gene of pasteurella multocida.

Colonisation of host tissue by Gram- negative bacteria is facilitated by various adhesins, one of which is type 4 fimbriae (pili). These structures have been associated with pathogenesis in several bacterial species, and have been shown to mediate colonisation of epithelial surfaces. Recently, type 4 fimbriae were identified and characterised from P. multocida strains A, B and D. The type 4 fimbrial subunit protein (PtfA) was identified as an 18-kDa protein which was isolated from whole membrane fractions. We report here the isolation and characterisation of the gene (ptfA) encoding the PtfA protein from P. multocida VP161 (serotype A:1). Part of the gene was cloned on a 2-kb genomic DNA fragment. The complete ptfA gene was obtained using inverse PCR. The gene and its flanking regions were characterised, and the deduced PtfA amino acid sequence was compared to type 4 subunit protein sequences from other bacterial species. The ptfA gene was amplified and sequenced from several P. multocida strains. Comparison of these sequences revealed variation within the type 4 subunit gene of P. multocida.

Cloning and characterisation of the Pasteurella multocida ahpA gene responsible for a haemolytic phenotype in Escherichia coli.

Haemolysins are membrane-damaging agents which have been described as bacterial virulence factors due to their ability to lyse erythrocytes and other host cells, and therefore inducing a greater inflammatory response (Elliott et al., 1998). Pasteurella multocida was found to be haemolytic under anaerobic conditions. In this study, we cloned and characterised a P. multocida gene, designated ahpA, which conferred a haemolytic phenotype on Escherichia coli when incubated under anaerobic conditions. A deletion was introduced into the ahpA open reading frame which abolished the haemolytic phenotype. The clone containing ahpA showed erythrocyte specificity, causing haemolysis of bovine and equine erythrocytes, and demonstrated weak haemolysis on ovine erythrocytes. Upon further investigation, AhpA was found to affect the expression of the E. coli K-12 latent haemolysin, SheA, under anaerobic conditions.

Yttrium-aluminum-garnet laser therapy of esophageal granular cell tumor.

BACKGROUND: Granular cell tumor (GCT) is a rare lesion. Approximately 4% to 6% of these tumors occur in the gastrointestinal tract, one-third of them affecting the esophagus. Almost all GCTs are benign lesions. Approximately 1% to 3% are malignant. Endoscopic ultrasonography (EUS) is a diagnostic support. The best treatment for esophageal GCT is not yet clear, whether surgical excision, periodic observation, endoscopic excision, or yttrium-aluminum-garnet (YAG) laser therapy. METHODS: From November 1992 to December 2000, four patients with GCTs of the esophagus were observed. All the patients underwent EUS evaluation and endoscopic YAG laser therapy of the esophageal neoplasm. At each session, a biopsy at the tumor site was obtained. The treatment was continued until endoscopic and histologic evidence of the tumor disappeared. RESULTS: After the YAG laser therapy, no evidence of the tumor was found in any of the four patients with esophageal GCT. At this writing, the patients remain disease free after a mean follow-up period of 66 months. No complication has been observed. Only four sessions for each patient were necessary to eliminate the tumor. CONCLUSIONS: Therapy with YAG laser was effective in all four patients with esophageal GCT, and complete necrosis of the submucosal neoplastic cells was achieved. Endoscopic YAG laser therapy appears to be a good compromise between esophageal dissection and long-term observation without tumor excision. Esophageal laser therapy is safe if correctly used, and previous EUS evaluation increases treatment safety.

[Prevalence of simple sporadic goiter in relation to other non-neoplastic thyroid pathologies in an internal medicine department]. / Prevalenza del gozzo semplice sporadico in rapporto ad altre patologie tiroidee non neoplastiche in una divisione di medicina interna.

BACKGROUND AND AIM: Thyroid pathologies, in particular goiter, are commonly found in everyday clinical practice in hospitalised patients. METHODS: The authors carried out a prospective type survey lasting 80 months in a mountain community with about 30,000 inhabitants with uniform socio-demographical characteristics. A total of 8,034 subjects (4,131 males and 3,903 females) were included in the study who were hospitalised in an Internal Medicine Department. All patients underwent screening using standard diagnostic criteria. RESULTS: Thyroid pathology was identified and classified into its various forms. There was a net prevalence of goiter which, owing to the unique features identified by the study, was defined as the sporadic form. The study demonstrated a marked prevalence in females, the familial pattern, the homogeneity of distribution throughout the area, the progression of disease with age and its evolution into immersed forms, the prevalence in both sexes in adults, the frequent use of surgery and its inherent problems, the inadequacy of treatment. CONCLUSIONS: The authors affirm that this pathology is regularly underestimated because it is not adequately identified, treated and monitored. They suggest a clinical and methodological approach based on a correct nosological definition, adequate diagnostic and prognostic stratification, an appropriate therapeutic protocol and clinical controls performed over time.

Antibiotic prophylaxis in clean surgery: breast surgery and hernia repair.

Use of prophylactic antibiotics in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach clean surgery. The question is more important for patients undergoing breast surgery. The presence of an infected breast wound delays the beginning of postoperative adjuvant anticancer therapy: there is good evidence to suggest that delayed adjuvant therapy compromises the outcome for patients in terms of both local control and survival. There are several clinical trials that have addressed the efficacy of prophylactic antibiotics for patients undergoing breast surgery and hernia repair. Platt et al assessed the efficacy of preoperative antibiotic prophylaxis in a clinical trial of 1218 patients undergoing clean surgery with an absolute reduction rate of 39% in wound infections. Gupta et al reported no influence on the incidence of infective complications by antibiotic prophylaxis in 357 patients undergoing elective breast surgery. Like breast surgery, use of prophylaxis in hernia repair is not clear: a prospective, randomized, double-blind, multicenter study of 619 patients assessed no benefit of antibiotic prophylaxis. On the other hand Lewis et al reported a 75% reduction of infections in low-risk patients when a single dose of cefotaxime was used in clean operations. A particularly interesting point is the use of prosthetic mesh in hernia repair and primary reconstructive surgery in breast surgery. Amland et al reported a significant reduction of the incidence of wound infections in a group of patients undergoing reconstructive breast surgery, receiving azithromycin vs placebo (5% vs 20%). In hernia repair we stress the need to prevent wound infections: currently Liechtestein's technique is widely performed all over the world. Mesh infection is an unpleasant event that requires prosthesis removal. The lack of conclusive studies about antibiotic prophylaxis in clean surgery suggests that a single-dose of cephalosporin at the induction of anesthesia may be prudent. This procedure is certainly inexpensive and safe and, more importantly, probably does not have an impact on antibiotic resistance.