World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS).

Timing of surgical intervention is critical for outcomes of patients diagnosed with surgical emergencies. Facing the challenge of multiple patients requiring emergency surgery, or of limited resource availability, the acute care surgeon must triage patients according to their disease process and physiological state. Emergency operations from all surgical disciplines should be scheduled by an agreed time frame that is based on accumulated data of outcomes related to time elapsed from diagnosis to surgery. Although literature exists regarding the optimal timing of various surgical interventions, implementation of protocols for triage of surgical emergencies is lacking. For institutions of a repetitive triage mechanism, further discussion on optimal timing of surgery in diverse surgical emergencies should be encouraged. Standardizing timing of interventions in surgical emergencies will promote clinical investigation as well as a commitment by administrative authorities to proper operating theater provision for acute care surgery.

Immunocytochemical assessment of p53 protein to detect malignancy in increased cell-yield brush cytology from the biliopancreatic tree.

BACKGROUND: Malignancies arising from the biliopancreatic tree are often diagnostic challenges for the gastroenterologist and the pathologist, especially when strictures without masses are present. AIM: To evaluate the diagnostic yield of p53 immunocytology for the detection of malignancies in material obtained by biliopancreatic tree brushing by means of an increased cell-yield procedure. PATIENTS AND METHODS: Cytologic specimens obtained from biliary and pancreatic tree brushing in 24 patients with biliary strictures suspected for malignancy were assessed by conventional Papanicolau staining and p53 immunocytochemistry. RESULTS: Papanicolau staining detected 67% and p53 87% of the malignancies in the study group. p53 immunocytology displayed excellent sensitivity, specificity, and diagnostic accuracy. CONCLUSIONS: p53 immunocytology may represent a useful diagnostic tool in the detection of malignancies from biliary and pancreatic tree brushing, especially when using an increasing cell-yield procedure.

Lymph node involvement in gastric cancer for different tumor sites and T stage: Italian Research Group for Gastric Cancer (IRGGC) experience.

BACKGROUND: The aim of lymphadenectomy is to clear all the metastatic nodes achieving a complete removal of the tumor; nevertheless, its role in gastric cancer has been very much debated. MATERIALS AND METHODS: The frequency of node metastasis in each lymphatic station according to the International Gastric Cancer Association, was studied in 545 patients who underwent D2 or D3 lymphadenectomy from June 1988 to December 2002. RESULTS: Upper third early cancers have shown an involvement of N2 celiac nodes in 25%. In advanced cancers, there was a high frequency of metastasis in the right gastroepiploic (from 10% in T2 to 50% in T4) and in the paraaortic nodes (26% in T2, 32% in T3, 38 % in T4). N3 left paracardial nodes involvement was observed in an important share of middle third tumors (17% in T3, 36% in T4). Splenic hilum nodes metastasis were common in T3 and T4 cancers located in the upper (39%) and middle (17%) stomach. N2 nodal involvement was frequent in lower third advanced cancers. Metastasis in M left paracardial and short gastric nodes were observed in a small percentage of cases. CONCLUSION: Given the nodal diffusion in our gastric cancer patients, extended lymphadenectomy is still a rationale to obtain radical resection.

The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients.

PURPOSE: To investigate whether the ratio between metastatic and examined lymph nodes (N ratio) is a better prognostic factor as compared with traditional staging systems in patients with gastric cancer regardless of the extension of lymph node dissection. PATIENTS & METHODS: We retrospectively reviewed the data of 1853 patients who underwent radical resection for gastric carcinoma at 6 Italian centers. Patients with >15 (group 1, n = 1421) and those with 25%) were determined by the best cut-off approach. RESULTS: After a median follow-up of 45.5 months (range, 4-182 months), the 5-year overall survival of N0, N1, and N2 patients of group 1 versus group 2 was 83.4% versus 74.2% (P = 0.0026), 54.3% versus 44.3% (P = 0.018), and 32.7% versus 14.7% (P = 0.004), respectively, suggesting that a low number of excised lymph nodes can lead to the understaging of patients. N ratio identified subsets of patients with significantly different survival rates within N1 and N2 stages in both groups. At multivariate analysis, the N ratio (but not N stage) was retained as an independent prognostic factor both in group 1 and group 2 (HR for N ratio 1, N ratio 2, and N ratio 3 = 1.67, 2.96, and 6.59, and 1.56, 2.68, and 4.28, respectively). In our series, the implementation of N ratio led to the identification of subgroups of patients prognostically more homogeneous than those classified by the TNM system. CONCLUSION: N ratio is a simple and reproducible prognostic tool that can stratify patients with gastric cancer also in case of limited lymph node dissection. These data may represent the rational for improving the prognostic power of current UICC TNM staging system and ultimately the selection of patients who may most benefit from adjuvant treatments.

Surgical treatment for gastric carcinoma in the elderly.

BACKGROUND AND OBJECTIVES: The incidence of gastric cancer is increasing in the elderly. The aim of this study is to evaluate the impact of advanced age (> or =80 years) on morbidity, mortality and late outcome after curative surgery for gastric cancer. METHODS: The cases of 30 octogenarians (Group A) with gastric cancer who underwent surgical treatment in our Institution from 1990 to 2003 were reviewed and compared to a simultaneous group of 228 younger patients (Group B). RESULTS: The rate of resective and curative procedures was not different in the two groups, although the American Society of Anaesthesiologists (ASA) risk was significantly higher in the elderly (P < 0.001) and the lymphatic dissection was less extended in group A. In the two groups, the curability was directly correlated to the cancer stage, but not affected by the ASA risk. The postoperative morbidity and mortality rates were similar in the two groups and were not related to the ASA risk. Considering the mortality for gastric cancer alone, the two groups showed a similar survival rate, only correlated to the cancer stage. CONCLUSIONS: In the elderly, an oncologically correct surgical procedure can safely be prosecuted with satisfactory immediate and late results.