Predictive Factors for Anastomotic Leakage after Laparoscopic and Open Total Gastrectomy: A Systematic Review.

The aim of this systematic review is to identify patient-related, perioperative and technical risk factors for esophago-jejunal anastomotic leakage (EJAL) in patients undergoing total gastrectomy for gastric cancer (GC). A comprehensive literature search of PubMed/MEDLINE, Embase and Scopus databases was performed. Studies providing factors predictive of EJAL by uni- and multivariate analysis or an estimate of association between EJAL and related risk factors were included. All studies were assessed for methodological quality, and a narrative synthesis of the results was performed. A total of 16 studies were included in the systematic review, with a total of 42,489 patients who underwent gastrectomy with esophago-jejunal anastomosis. Age, BMI, impaired respiratory function, prognostic nutritional index (PNI), alcohol consumption, chronic renal failure, diabetes and mixed-type histology were identified as patient-related risk factors for EJAL at multivariate analysis. Likewise, among operative factors, laparoscopic approach, anastomosis type, additional organ resection, blood loss, intraoperative time and surgeon experience were found to be predictive factors for the development of EJAL. In clinical setting, we are able to identify several risk factors for EJAL. This can improve the recognition of higher-risk patients and their outcomes.

Mycosis fungoides (CTCL) associated with colorectal adenocarcinoma. A rare case of combined response to neoadjuvant therapy.

Mycosis fungoides (MF) is a well-known and common form of cutaneous T-cell lymphoma (CTCL), composed of malignant proliferation of CD4+CD45Ro+helper memory T cells. In the patient with MF, the incidence of secondary malignancies is higher than general population but very few cases with both MF and colorectal adenocarcinoma have been reported. Herein we describe a case of MF occurring in a 64-year-old man and followed, five months later, by a diagnosis of colorectal adenocarcinoma. Of notice, simultaneous regression of both rectal mass and cutaneous MF manifestations was observed after administration of chemioradiation therapy prior to rectal surgery. The patient is alive and in stable clinical remission at eight years from the diagnosis. KEY WORDS: CTCL, Colorectal adenocarcinoma, Mycosis fungoides, PUVA.

Obstructing left sided colorectal cancer. A retrospective single Center study.

BACKGROUND: In recent years, with population aging, there has been an increased number of colorectal cancer cases with severe occlusion symptoms. About 75% of obstructions due to malignant colorectal cancer (10-30%) occur distal to splenic flexure. METHODS: The authors evaluated the best surgical therapeutic strategy to be used in cases of left-sided colorectal carcinoma in patients over 65 years old, especially considering the emergency condition, age of patients and efficacy in terms of postoperative morbidity, mortality and 5 years survival rate. RESULTS: The management of left-sided obstructing colorectal carcinoma is controversial. Hartmann's procedure is the best therapeutic choice in elderly patients. However, resection with intraoperative colonic wash-out and primary anastomosis has favorable outcome in low risk patients. CONCLUSIONS: A review of the literature reveals that primary resection and anastomosis for left-sided obstructing CRC is the correct therapeutic strategy in low risk patients with localized, resectable carcinoma, without peritonitis; Hartmann's procedure should be adopted in doubtful cases and in high risk patients.

Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review.

INTRODUCTION: Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION: A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS: Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS: The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.

Percutaneous endoscopic gastrostomy (PEG), in elderly patients with dementia and anorexia. Medical and ethical issues regarding placement.

BACKGROUND AND AIMS: Ethical and medico-legal issues reviews of Percutaneous Endoscopic Gastrostomy (PEG) placement in elderly patients is an important topic of international medical literature. PEG is often inappropriately placed in patients with not spontaneous oral feeding intake, cause of unrealistic expectations. We performed a critical review of the literature for placement of PEG in geriatric patients. METHODS: A literature review was performed about the positioning of the PEG in geriatric patients with dementia and severe anorexia. This assessment has served to develop an algorithm that would be able to provide adequate indications for PEG placement in this patient population. RESULTS: We obtained appropriate indications about PEG placement, below: 1) Esophageal obstructions (like esophageal or neck cancer) 2) neurological deficits correlated dysphagia (like ictus sequelae) 3) refusal to swallow without concomitant terminal illness (like protracted pseudo dementia caused by severe depression) 4) chronic gastric decompression in patients with benign/malignant obstruction who do not wish or can't have a nasogastric tube placed. CONCLUSIONS: When compared with controls matched for age, elderly patients with cognitive impairment who have feeding gastrostomy do not demonstrate improved survival. KEY WORDS: Anorexia, Dementia, Elderly, Percutaneous Endoscopic Gastrostomy.

Emergent treatment of carotid stenosis: an evidence-based systematic review.

INTRODUCTION: Stroke is one of the major causes of death in the world, but above all is the condition most associated with severe long-term disabilities. It is clear that this condition therefore requires the best therapeutic approach possible to minimize the consequences that this can lead to. The major issues concern the type of treatment to be used for revascularization (carotid endarterectomy [CEA] or stenting of the carotid artery [CAS]) and the timing of the treatment itself. Many studies have been conducted on this issue, but a definitive and unanimous verdict has not yet been reached on account of the great variety of results obtained from the various study group. The aim of this review is to analyze the latest scientific findings focused on revascularization following a symptomatic carotid stenosis (SCS). EVIDENCE ACQUISITION: We searched all publications addressing treatments and timing of approach to SCS. Randomized trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Medline and Science Direct were searched from January 2013 to April 2017. EVIDENCE SYNTHESIS: Of the 819 records found, 76 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 54 manuscripts because of the following reasons: 1) no innovative or important content; 2) insufficient data; 3) no clear potential biases or strategies to solve them; 4) no clear endpoints; and 5) inconsistent or arbitrary conclusions. The final set included 22 articles. CONCLUSIONS: CEA is considered a less problematic method than CAS, especially for patients over the age of 75; CAS remains recommended in patients with a favorable anatomy or high surgical risks. Studies that showed more solid results seem to lead to the conclusion that optimal timing may be between 2 days and the end of the first week from the onset of symptoms in patients who are appropriate candidates for surgery.

Fondaparinux vs warfarin for the treatment of unsuspected pulmonary embolism in cancer patients.

INTRODUCTION: In cancer patients, the chest computer tomography (CT) can be used to identify asymptomatic pulmonary embolism (APE). In most cases, these patients are treated with anticoagulant drugs for at least 3 months. The American College of Physicians recommend treatment of these patients as patients with symptomatic pulmonary embolism. In this study, we evaluated and compared the efficacy and safety of fondaparinux vs warfarin in the prevention of unsuspected pulmonary embolism in patients with active cancer. MATERIALS AND METHODS: A prospective and parallel group study was performed on 64 cancer patients (29 males and 35 females) with APE. A multidetector CT angiography with high spatial and temporal resolution and quality of arterial opacification was used to make the diagnosis. Lung scintigraphy was reserved to selected patients only. Patients were randomized to either the warfarin (Group A) or the fondaparinux (Group B) for 90 days. The first end point of efficacy was the persistence, reduction, or disappearance of thrombosis after 90 days. The second end point was the reappearance of thrombosis after 1 year. The first end point of safety was the development of major bleeding. RESULTS: We enrolled 32 patients into each treatment group. We reached the first end point of efficacy and safety in Group B which showed that fondaparinux was able to induce the disappearance of thrombotic pulmonary with a lower incidence of major bleeding events compared with warfarin. No difference in the secondary end point was recorded. CONCLUSION: We suggest that the treatment of cancer patients with APE can be oriented with the administration of a standard dose of fondaparinux until the next CT lung control (3 months). However, the lack of a randomized clinical trial, including a larger patient cohort, does not allow formulation of final recommendations in these patients. A broader study would be desirable, involving a larger number of patients and a longer follow-up period.

Tailored treatment of intestinal angiodysplasia in elderly.

BACKGROUND: Angiodysplasia of the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and severe anemia in elderly. Different treatments exist for this kind of pathology. METHODS: The aim of this work was to study 40 patients treated for intestinal angiodysplasia with two different kind of endoscopic treatments: argon plasma coagulation (APC) and bipolar electrocoagulation (BEC). RESULTS: Age of patients was similar in both groups (76,2 ± 10.8 years vs 74,8 ± 8,7 years, P = 0,005). Angiodysplasia treated were located in small bowel, right colon, left colon, transverse colon and cecum. We analysed number of treatment, recurrence, hospital discharge, needs of blood transfusions before and after endoscopic treatment. Number of treatment was the same in both groups (1,2 ± 0,2 vs 1,1 ± 0,1, P < 0,001). We had more recurrence in patients treated with BEC (4/20 vs 2/20, P < 0,001). Hospital discharge was comparable in both groups (5,3 ± 3,1 days vs 5,4 ± 2,8 years, P < 0.001). CONCLUSIONS: Treatment of angiodysplasia in elderly is not easy. Different kinds of treatment could be adopted. APC and BEC are both safe and effective. The choice of a treatment should consider several factors: age, comorbidity, source of bleeding. In conclusion we think that treatment of bleeding for angiodysplasia in elder population should be a tailored treatment.

The incidence of thyroid carcinoma in the nodules. A retrospective study.

UNLABELLED: Fine-needle aspiration (22G) is the diagnostic procedure chosen to study the nature of suspicious thyroid nodules. In 2008 the SIAPEC-IAP work group issued the results of Italian Consensus about the clinical management of patients with thyroid nodular disease, and introduced diagnostic categories aimed to standardize the diagnostic and therapeutic process of patients affected by thyroid nodules. This retrospective study is aimed to assess the incidence of carcinoma at definitive histological examination after total thyroidectomy of nodules with TIR3 cytological diagnosis. KEY WORDS: CEUS, FNAC, Surgery, Thyroid nodules.

Surgical mistake causing an high recto-vaginal fistula. A case report with combined surgical and endoscopic approach: therapeutic considerations.

BACKGROUND: Rectovaginal fistulas (RVFs) have multiple causes, size and location on which the surgical treatment depends. DESCRIPTION: The Authors consider different approaches to RVFs and describe a clinical case of recurrent high RVF. CONCLUSIONS: Most RVFs can be successfully repaired, although many interventions may be necessary. A colostomy with delayed repair may improve RVFs outcome. Moreover, several authors indicate Mucosal Advancement Flap and Babcock-Bacon technique as the treatments of choice respectively for low and high RVFs (complex and recurrent) and emphasize the placement of endoscopic prothesis in cases of difficult healing of the anastomosis.

Breast cancer surgery in elderly patients: postoperative complications and survival.

AIMS AND BACKGROUND: Old age is associated with comorbidity and decreased functioning which influences treatment decisions in elderly breast cancer patients. The purpose of this study was to identify risk factors for complications after breast cancer surgery in elderly patients, and to assess mortality in patients with postoperative complications. METHODS: We retrospectively considered all female patients aged 65 years and older with invasive and in situ breast cancer who were diagnosed and treated between 1997 and 2012 in the Department of General and Geriatric Surgery of the University of Naples "Federico II". RESULTS AND CONCLUSION: 449 patients received surgery, of whom 18,2% (n = 82) developed one or more postoperative complications. The odds ratio of having postoperative complications show an increase with age, reaching statistical significance only for patients older than 85 [OR 5,75 (95% confidence interval 2,38-14,04); p < 0,001]. Number of concomitant diseases [OR 2,51 (95% CI 1,17 - 5,45); p = 0,01 for 3 or more concomitant diseases] and polypharmacy [OR 16,7 (95% CI 9,12 - 30,58); p < 0,0001) are associated to an increased risk of postoperative complications. Overall survival was worse in patients with postoperative complications [HR 2,06 (95% CI 1,52-2,70), p < 0,001]. This increased risk of mortality is probably due to geriatric parameters such as comorbidity or poor physical function, more than to higher complication rates.

Undertreatment of breast cancer in the elderly.

AIMS: The effect of undertreatment with adjuvant hormonal therapy, chemotherapy or radiation was studied in elderly women with breast cancer. METHODS: A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1997 and 2011. The presentation, pathologic findings, treatment and outcomes of 449 women over 65 were compared to the findings in 1049 younger patients. Moreover, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared. RESULTS: Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were signicantly more favorable than cancers in younger patients with more infiltrating lobular, fewer ductal carcinoma in situ and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary surgery, less adjuvant radiation therapy and more hormonal therapy. Fourty-six percent of the 449 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during follow-up without disease recurrence. CONCLUSIONS: Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated.

Day-surgery inguinal hernia repair in the elderly: single centre experience.

BACKGROUND: Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients. METHODS: A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups. RESULTS: Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients. CONCLUSIONS: Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.

Emergency groin hernia repair: implications in elderly.

BACKGROUND: Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients. METHODS: We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications. RESULTS: A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died. CONCLUSIONS: Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

BACKGROUND: Inguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia. METHODS: The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia. RESULTS: Evaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics. CONCLUSIONS: Clinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling.

Unusual case of exacerbation of sub-acute descending necrotizing mediastinitis.

Descending necrotizing mediastinitis is a life-threatening complication of an oropharyngeal infection that requires prompt and aggressive medical and surgical therapy. Herein, we report unusual case of man suffering of sub-acute mediastinal infection due to odontoiatric abscess which exacerbated at 3 months after its first presentation. Chest X-ray and CT scan demonstrated soft-tissue swelling of the neck and encapsulated fluid collections with gas bubbles within anterior mediastinum, especially on the right side. Bilateral anterior neck dissections were performed and blunt dissection, irrigation and debridement were carried out to several centimetres below the sternal manubrium. Then, right standard thoracotomy was performed with debridement of the anterior mediastinum. Four tubes were placed in the mediastinum and pleural cavity on the right side, and two tubes were placed in the left thoracic cavity. Follow-up CT scans of neck and chest showed the resolution of infection.

Migration of surgical clips through a right lobectomy stump mimicking an asthmatic syndrome.

The mechanical stapler is routinely used in thoracic surgery practice to attend resection of bronchus and vessels. Herein, we reported a very rare complication as the migration of a titanium surgical clip through a right lobectomy stump. One year after the procedure, the patient complained of persistent cough. A misdiagnosis of asthma was made and she treated for 6 months with bronchodilators, corticosteroid and antihistaminic without success. Thus, patient re-referred of our unit. No clinical signs of infection as fewer, productive cough, dyspnea were present. The laboratory exams were within normal value including white cells. CT scan revealed no abnormalities. Bronchoscopy demonstrated a healed upper bronchus stump without evidence of an actual, open bronchopleural fistula but with clips apparently working their way into the airway, with approximately half of the clip visible within the lumen. The side of the clips that would be open before closure by the surgeon formed the leading edge of the clips visible in the lumen. The clips were successfully removed during flexible bronchoscopy with a forceps usually used for biopsy. After the procedure, the cough disappeared. The endoscopy check after 3 months showed a normal bronchial stump without evidence of fistula.

Upper extremity vein thrombosis: an alert symptom of breast cancer in elderly patients. Experience on personal casuistry and review of the literature.

BACKGROUND: Breast Cancer in elderly patients is a significant health problem representing an important source of morbidity and mortality. Although the most common presentation is the presence of a palpable lump there may be, especially in the elderly population, rare clinical manifestations such as thromboembolic events that often involve the upper limbs. METHODS: We retrospectively reviewed a ten year clinical casuistry of patients with Breast Cancer who presented for an initial diagnosis of upper extremity vein thrombosis. RESULTS: 13 patients with initial diagnosis of upper limbs vein thrombosis (1M-12 F; age range 48-76; median age 70 years) resulted affected from Breast Cancer. The diagnosis of vein thrombosis represented the first clinical manifestation related to thier malingancy. All patients of our casuistry had positive ER/PR receptor status. CONCLUSIONS: A case of upper vein extrmity thrombosis in an elderly patient should prompt a high index of suspicion for breast malignancy in order to avoid diagnostic delay that may retard appropriate treatment.

Decision making in borderline ovarian tumors: report of a rare case of mesosigma psammocarcinoma.

Psammocarcinoma is a rare variant of serous carcinoma arising either from ovary or peritoneum, characterized by massive psammoma body formation, low-grade of cytologic differentiation and invasiveness. Its clinical behavior is similar to the serous borderline tumors, whose prognosis is significantly better compared to invasive forms, with a 5-year survival in stage I greater than 95%. A typical feature of borderline ovary tumors is the presence, in more than 30% of cases, of borderline peritoneal implants similar to primary ovarian cancer or of invasive forms. We report a case of a 44-years-old woman who referred to our clinic for mesosigmoid mass , accidentally discovered by ultrasonography. Sigmoidectomy with fertility sparing surgery was performed in september 2010. The mass was hystologically characterized by many psammoma bodies and low grade cytological features with diagnosis of psammocarcinoma of mesosigma. One year after the primary surgery, the patient showed with left adnexial mass; optimal debulking surgery was performed including omentectomy, total abdominal hysterectomy, bilateral adnexectomy and appendicectomy. The patient did not receive any adjuvant chemotherapy and to date she is alive and with no evidence of disease. The conclusion is that psammocarcinoma is a very rare tumor that behaves less aggressively than typical serous carcinoma, the mainstay of treatment is surgical debulking , with fertility sparing surgery as possible option in young patients with ovaries macroscopically free of disease.