Tissue reconstruction of abdominal wall with butyric acid-based nets: preliminary in vitro test using tissue engineering strategies.

OBJECTIVE: A hernia of the abdominal wall is an opening of the muscles in the abdominal wall, which is frequently treated via the application of a surgical mesh. The purpose of this research is to study how human adipose-derived stem cells (hADSCs) interact with Phasix™ Mesh, a commercially available mesh for hernia repair. Studying how cells derived from the abdominal region behave with Phasix™ Mesh is crucial to improve the state of the art of current surgery and achieve effective tissue restoration. MATERIALS AND METHODS: hADSCs were seeded onto Phasix™ Mesh, a fully resorbable surgical mesh of poly (4-hydroxybutyric acid) (P4HB). Cell viability was assessed through MTT assay, and cell growth and adhesion were evaluated via multiple imaging techniques and gene imaging profiling. RESULTS: Results confirm that the nets support cells proliferation, extracellular matrix production and increasing of angiogenetic factor. CONCLUSIONS: Butyric acid-based nets are promising scaffolds for abdominal wall reconstruction.

Mesh-tissue integration of synthetic and biologic meshes in wall surgery: brief state of art.

Many studies show that surgical hernia repair with the use of prosthetic meshes can result in pain, hernia recurrence, contraction and mesh rupture. Numerous experimental studies have been conducted to understand the effect of mesh stiffness, pore size and mesh patterns on mesh biocompatibility. The purpose of this mini review is to present an overview of the contracture, adhesion, tissue regrowth and histological response characteristics of permanent and absorbable mesh. Indeed, the mechanics of mesh-human tissue interaction is poorly understood in the literature. It has been shown that early integration of biological meshes is critical for sustained hernia repair. One of the emerging experimental approaches is to combine cell-based regenerative medicine with mesh materials. Studies in preclinical models show that the use of synthetic and biological meshes with autologous cell implantation improves the biocompatibility of biomaterials, promoting key tissue regeneration processes such as adhesion and vascularisation.

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients.

PURPOSE: To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS). METHODS: Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014. RESULTS: Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3-4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS. CONCLUSIONS: Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients' characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

Primary anorectal melanoma: an update.

The anorectum is a rare anatomic location for primary melanoma. Mucosal melanoma is a distinct biological and clinical entity from the more common cutaneous melanoma. It portrays worse prognosis than cutaneous melanoma, with distant metastases being the overwhelming cause of morbidity and mortality. Surgery is the treatment of choice, but significant controversy exists over the extent of surgical resection. We present an update on the state of the art of anorectal mucosal melanoma. To illustrate the multimodality approach to anorectal melanoma, we present a typical patient.

Primary breast cancer features can predict additional lymph node involvement in patients with sentinel node micrometastases.

OBJECTIVE: The aim of this retrospective study was to identify biological features of primary breast cancer from which to predict the presence of further axillary involvement in patients bearing micrometastases in the sentinel lymph node (SLN). METHODS: From a starting group of 690 patients, we isolated patients with micrometastases in the SLN. Those patients were classified according to the presence/absence of further metastases in nonsentinel lymph nodes (NSLNs). We examined primary tumor features to identify any relevant difference. Analysis of primary tumors evaluated histology, tumor size, lymphovascular invasion, mitotic index (Mib-1), estrogen and progesterone receptor status (ER/PR status), C-erb B-2 (HER-2/neu) expression and amplification, and p53 expression. Chi square analysis for statistical significance was applied. RESULTS: Of the original 690 patients, 296 showed some kind of metastases in the SLN; 238 patients had gross metastases in the SLN. After axillary lymph node dissection (ALND), 102 patients (43%) had NSLNs with metastases, and 136 (57%) had negative axillary non-sentinel nodes. Another 58 patients harbored solitary micrometastases in the SLN. After ALND, 8 (14%) patients had further NSLN involvement, and 50 (86%) had negative axillary nodes. CONCLUSIONS: Analysis of the primary breast lesion in patients with micrometastatic SLN and metastatic NSLNs revealed the presence of lymphovascular invasion, Mib-1 index > 10%, and tumor size > 2 cm. Patients without lymphovascular invasion, Mib-1 < 10% and T size < 2 cm could avoid further ALND.

Accuracy and reliability of sentinel node biopsy in patients with breast cancer. Single centre study with long term follow-up.

The aim of our study is to evaluate the frequency of false-negative (FN) sentinel node procedures in patients with breast cancer. A total of 791 breast cancer patients underwent sentinel lymph node (SLN) biopsy at our institution between July 1997 and February 2005. A 2-day protocol was used to localise the sentinel node with the injection of 99mTc-nanocolloid. There were two phases in the study: the learning phase (50 patients) and the application phase (741 patients). In the learning phase, a complete lymphadenectomy was always performed. In the application phase, sentinel nodes were studied postoperatively with breast cancer and lymphadenectomy was performed when considered warranted by the pathological postoperative results. The median follow-up duration in the 741 patients studied during the application phase was 32.3 months (range 6-72 months). In this phase a total of 787 sentinel nodes (719 axillary and 68 intramammary chain) were obtained (range 0-5 per patient, mean 1.01), with 153 (41 with micrometastasis) positive sentinel nodes. We observed a total of three FN SLN results (0.5%). All three presented as an axillary recurrence into 24 months from operation. After a median follow-up of 32.3 months we observed only three clinical recurrences among 741 patients. Our results indicate that the sentinel node protocol can give an adequate local control.

A new approach to the cure of the Ogilvie's syndrome.

The Authors describe a their own observation of 25 cases of acute colonic pseudo obstruction, better known as "Ogilvie Syndrome" with the objective to demonstrate that an early recognition and prompt appropriate therapy, better if conservative, can reduce the morbidity and the mortality of the Syndrome. The surgical therapy is reserved only to that cases in which the risk of perforation of the cecum represent an absolute indication to intervention.

Reliability and accuracy of sentinel node biopsy in cutaneous malignant melanoma.

AIMS AND BACKGROUND: The aims of this study were 1) to investigate whether sentinel lymph node (SLN) biopsy could become the method of choice for the early detection of metastatic disease in patients with malignant melanoma and 2) to identify those patients with lymph node metastases who could benefit from regional lymphadenectomy. METHODS AND STUDY DESIGN: Our study started in March 1998 and involved 110 patients with primary cutaneous malignant melanoma stage I or II (AJCC) in whom the primary lesion had been surgically removed no more than 90 days previously. On the day of lymph node dissection patients were given an intradermal injection of colloid particles of human serum albumin labeled with technetium-99m and an injection of isosulfan blue. The surgical procedure was usually performed with local anesthesia but in some cases locoregional or general anesthesia was preferred. Contralateral and ipsilateral lymphatic areas were scanned with a hand-held gamma camera (Scintiprobe MR 100) to measure the background and identify the hot point indicating the location of the sentinel node to direct the incision. RESULTS: The combined use of lymphoscintigraphy, isosulfan blue and gamma probe allowed us to identify sentinel nodes in 108 of 110 patients (98.18%) while the SLN was blue in only 90 cases (81.81%). The SLN was positive for metastases in 13 of the 108 patients (12.03%) and regional and distal lymphadenectomy was performed in all of them. The distribution of positive SLNs by primary lesion thickness was as follows: 0.76-1.5 mm: one positive SLN/44 patients (2.27%); 1.51-4 mm: six positive SLNs/51 patients (11.7%); > 4 mm: six positive SLNs/15 patients (40%). Only four of 12 patients with ulcerated cutaneous melanoma had positive SLNs. The patients in our study underwent follow-up visits every four months. The median follow-up was 481 days (range, 97-1271 days). CONCLUSIONS: In patients with primary cutaneous melanoma the histological status of the SLN accurately reflects the presence or absence of metastatic disease in the relevant regional lymph node basin. Complete lymph node dissection should only be performed in patients with positive SLNs. Patients with lesions > 4 mm are likely to develop recurrences and to die of systemic disease, so in these patients the usefulness of SLN biopsy is questionable. In conclusion, sentinel node mapping is a rational approach for the selection of patients who might benefit from early lymph node dissection of the affected basin.

Prognostic and therapeutic impact of sentinel node micrometastasis in patients with invasive breast cancer.

AIMS AND BACKGROUND: Locoregional lymph node status is one of the most important prognostic factors determining the need for adjuvant chemotherapy in patients with breast cancer. Many authors have reported that micrometastases were not detected by routine sectioning of lymph nodes but were identified by multiple sectioning and additional staining. Among lymph node-negative patients 15-20% had an unfavorable outcome at five years from primary surgery. Sentinel lymph node (SLN) biopsy is an accurate technique for identifying axillary metastases because the pathologist utilizes hematoxylin-eosin (H-E) staining together with immunohistochemistry (IH) to examine all lymph node sections. Sentinel node micrometastasis has therefore become an important tumor-related prognostic factor. METHODS AND STUDY DESIGN: From November 1997 to October 2001 we examined in 210 patients the pathological features of primary breast lesions and SLN metastases and we correlated these with the tumor status of non-SLNs in the same axillary basin. We applied IH examination to both SLNs and non-SLNs of patients who were negative for metastasis by standard H-E examination. RESULTS: In this study lymph node staging was based on SLN findings, primary tumor size and the presence of peritumoral lymphovascular invasion (LVI). We found 18 SLN micrometastases (9%) in 210 patients and one of these (5.5%) of patients with SLN micrometastasis) also had one non-SLN metastasis: this patient had LVI and a larger primary tumor than patients with SLN micrometastasis without non-SLN metastasis. We also found 24 SLN macrometastases (11.5%) in 210 patients and 13 of these (54.2% of patients with SLN macrometastases) had one or more non-SLN metastases. CONCLUSIONS: According to the results reported in the literature, tumor cells are unlikely to be found in non SLNs when the primary lesion is small and SLN involvement micrometastatic (5.5% in our experience, 7% in Giuliano's). Our findings suggest that axillary lymph node dissection may not be necessary in patients with SLN micrometastasis from T1 lesions.

Sentinel node biopsy in the evaluation of the internal mammary node chain in patients with breast cancer.

AIMS AND BACKGROUND: In patients with breast cancer the presence of internal mammary chain (IMC) metastases changes tumor staging, and the occurrence of IMC drainage is quite common in breast cancer. Nevertheless, IMC dissection is not a routine procedure in modern surgical approaches towards breast cancer. We therefore need minimally invasive techniques for accurate assessment of the IMC nodal basin. The aim of this study was to investigate whether sentinel node biopsy (SLNB) could offer a solution. METHODS AND STUDY DESIGN: From November 1997 to June 2001 143 female patients who were eligible for breast cancer surgery were included in the study. All patients had T1 breast cancer and clinically negative axillae. Patients were submitted to preoperative lymphoscintigraphy with subsequent SLNB. We used a 99m-technitium nanocolloid tracer (Nanocoll) that was injected peritumorally so as to have about 10 MBq of radioactivity at the time of surgery. Scintigraphy was performed about 17 hours after tracer administration. During surgery, lymphoscintigraphic imaging and a gamma ray detection probe were used to locate the sentinel node. Histological examination after embedding in paraffin was usually requested and multilevel sectioning of the sentinel node (SLN) was performed, with hematoxylin and eosin staining and immunohistochemistry. RESULTS: Preoperative lymphoscintigraphy localized SLNs in the IMC basin in 27 of 143 patients (18.9%). Harvesting of IMC-SLNs based on lymphoscintigraphy results was successful in 20 of 27 patients (74.1%). Histological examination revealed micrometastases in four of the 20 harvested nodes. One of these patients showed no axillary drainage and no axillary lymph node dissection was therefore performed. In the remaining three patients also axillary SLNs were harvested, which turned out to be free from metastatic involvement. CONCLUSIONS: In our experience lymphoscintigraphy with SLNB was an accurate method to detect IMC metastases in patients with breast cancer. We recommend peritumoral tracer injection and a reasonable interval between injection and scintigraphy. IMC-SLN biopsy did not result in any serious additional complications or morbidity. In our study this approach led to improved cancer staging: four of 20 harvested IMC-SLNs proved to be micrometastatic. None of these four patients had metastatic axillary SLNs. Exclusive drainage to the IMC is present in only a small number of breast cancer patients, and our results suggest that it is possible to avoid unnecessary axillary node dissection in such cases.

A new device for sutureless skin closure "the zipper".

BACKGROUND: We have done a prospective, controlled, randomized study to investigate the role of the "zipper", a new device for skin closure. We have also analysed morbility and advantages with the use of the "zipper" compared with sutures. METHODS: 610 consecutive patients underwent surgery for abdominal thoracic endocrinologic and post traumatic pathologies. In 203 cases we used the zipper a new device for skin closure. RESULTS: 6/203 Morbility: in six cases it was necessary to substitute the zipper with sutures or leave the wound healing by second intention. The patients were operated for inguinal hernioplasty, axillary lymphadenectomy, appendicectomy and cholecystectomy. These patients developed complications after surgery as hematoma, lymphorrhea, wound infection and a reintervention. The correction has been done removing the zipper and positioning sutures or leaving the wound healing by second intention. CONCLUSIONS: The use of the zipper permits to achieve an efficient seal, a simple application, an aesthetic comfort; it can be applied in local anaesthesia and for its painless, application it is indicated in pediatric surgery.

Acute colon diverticulitis in multiple myeloma patient: an unusual presentation of a colonic perforation. Case report.

This case report describes an acute colonic diverticular perforation occurred to a multiple myeloma patient, taking corticosteroid and morphine therapy, revealed by a subcutaneous emphysema of upper chest and right abdomen as initial presentation. Sigmoid diverticulitis with perforation and generalized peritonitis is a severe complication of the diverticular disease and it is due to diverticular microperforation. This condition occurs more frequently in patients with widespread diverticolosis and usually after 50 years of age, and the frequency of related complications increases with age (and with the use of corticosteroids). Extraperitoneal air from the sigmoid-rectum perforation can escape diffusing superiorly though paravertebral retroperitoneal tissues and via the diaphragmatic iatus into the mediastinum, producing pneumomediastinum and it diffuses to yield superior thoracic emphysema. This report suggests that the diagnosis of retroperitoneal perforation is usually difficult because of the lack of signs of peritoneal irritation and the paucity of symptoms, particularly in patients treated with corticosteroids.

An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation.

A modern approach to the surgical treatment of early breast carcinoma requires intraoperative localisation of non-palpable lesions and assessment of the lymph node status. Localisation of breast lesions can be achieved by intratumoural injection of a small amount of radiotracer and intraoperative use of a gamma probe (i.e. radioguided occult lesion localisation, or ROLL). Assessment of the lymph node status is possible by means of the sentinel node approach. To date, two different radiopharmaceuticals have been used for localisation of tumour and sentinel node. We now propose the use of a single nanocolloidal tracer (Nanocoll, with a particle size of less than 80 nm) which is labelled with technetium-99m for simultaneous performance of ROLL and sentinel node identification. The aim of this study was to evaluate the feasibility of this approach, which should be easier and more practical than the dual-tracer injection method. We have employed this new technique in 73 patients with non-palpable, cytologically diagnosed breast cancer and non-palpable axillary lymph nodes. In all patients the radiocolloid, in a total volume of 0.3-0.4 cc, was injected under sonographic or stereotactic guidance. Half of the dose was injected intratumourally and half superficially, but very close to the tumour. Because of the slow lymphatic flow in the breast, Nanocoll must be injected some time before surgery in order to enable adequate migration to the axilla. We injected colloid in the afternoon before surgery (16-23 h before the start of the operation, with an average interval of 18 h). An average dose of 130 MBq (range 110-150) was injected in order to have about 10 MBq of radioactivity when surgery commenced. Lymphoscintigraphy was performed after 15-19 h, with an average interval of 17 h. The procedure was always successful in permitting the localisation of occult breast lesions. Lesions were always localised at the first attempt, and were always contained within the surgical margins. Histological examination revealed all 73 resected lesions to be malignant: there were 64 cases of infiltrating carcinoma and nine of intraductal carcinoma. All breast lesions were therefore confirmed to be early breast cancer. We achieved sentinel node localisation in 71 out of 73, either at scintigraphy or with the intraoperative probe; in two patients, radiopharmaceutical migration was absent. Lymphoscintigraphy showed only axillary drainage in 52 cases, only internal mammary chain (IMC) drainage in nine cases, and combined axillary and IMC drainage in eight cases. In two cases, lymphoscintigraphy suggested the sentinel node was located inside the same breast (intramammary lymph node). All the visualised sentinel nodes were biopsied except for four that were localised in the IMC. Histological examination of the nodes showed metastases in 20 cases: in 15 cases there were micrometastases, and in five, macrometastases. In conclusion, this study has demonstrated the feasibility of the proposed procedure. Simultaneous performance of ROLL and sentinel node localisation using a single tracer represents a useful and practicable choice in the management of early breast cancer.