The prognostic role of metastatic lymph node ratio in colon cancer: a retrospective cohort study on 241 patients in a single center.

BACKGROUND: The detection of nodal status is based on examination of lymph nodes (LN) after the tumor surgical resection and the current guidelines recommend examining at least 12 regional LN. An inadequate number of examined LN may lead to a lower N stage or to a false-negative nodal disease. To overcome these issues, many authors proposed to consider the metastatic lymph node ratio (mLNR). MLNR is the ratio of the number of metastatic LN to the number of examined LN. METHODS: Two hundred forty-one colon cancer (CC) specimens from patients who had undergone surgical resection between January 2010 and December 2015 at the General Surgery Unit of Parma University Hospital were analyzed. mLNR, which is defined as the ratio of the number of positive LN to the number of examined LN, was calculated in CCs with LN metastasis. In this study we focused on the following mLRN cutoffs: <0.15, 0.15-0.3 and >3 and we evaluated the prognostic implication of mLNRs. RESULTS: Regarding the impact of examined LN on involved LN in CC, our results showed that the number of involved LN increased with the increasing number of examined LN (P=0.03). We found a significant correlation between OS and RFS rate of patients with CCs and mLNR. Patients with mLNR<0.15 were associated with better OS and RFS rate whereas patients with mLNR>0.3 were associated with worse OS and RFS rate. OS rate for patients with a mLNR<0.15 was 95.24% (89-100%) at 1 year, 83.27% (72.7-95.4%) at 3 years and 68.07% (55.1-84.1%) at 5 years whereas patients with a mLNR>0.3 had an OS rate of 51.7% (34.6-77.3%) at 1 year, 36.55% (20.08-64.3%) at 3 years and 31.33% (16.5-59.4%) at 5 years. RFS rate for patients with a mLNR<0.15 was 100% (100-100%) at 1 year, 92.2% (84-100%) at 3 years and 85.2% (73.8-98.31%) at 5 years whereas patients with a mLNR>0.3 had a RFS of 63.2% (42.8-93.58%) at 1 year and 54.2% (33.1-88.93%) at 3 and 5 years. CONCLUSIONS: The prognostic value of pN stage could be more accurate if we consider both the number of LN metastasis and harvested LN. This can be achieved by using the mLNR that can be a useful tool in daily practice to predict the prognosis of patients who undergone surgery for CC.

The metastatic lymph node ratio is a better prognostic factor than the number of metastatic limph node after curative resection for gastric cancer.

AIM: Evaluate impact of lymph node ratio as prognostic factor in gastric cancer. METHODS: We studied 463 patients with gastric cancer who underwent curative gastric surgery with D1 or D2 lymphadenectomy, Data were collected from May 1996 through December 2010 at Department of General Surgery of Parma University Hospital. We divided patients in two groups according to number of nodes removed Results: The results of the present nonrandomized retrospective single centre study confirm the promising role of the LNR as an independent prognostic factor. Overall survival between LNR categories are statistically significant different between LNR0 and LNR1. CONCLUSION: The ratio between the number of metastatic and analysed lymph nodes in patients with gastric cancer can discriminate patients better than the AJCC/UICC staging system: it seems to be related to a more sensitive in the evaluation of overall survival.

Three distinct outcomes in patients with colorectal adenocarcinoma and lymphovascular invasion: the good, the bad, and the ugly.

PURPOSE: In colorectal cancer (CRC), lymphovascular invasion (LVI) is a predictor of poor outcome and its analysis is nowadays recommended. Literature is still extremely heterogeneous, and we hypothesize that, within such a group of patients, there are any further predictors of survival. METHODS: A total of 2652 patients with I-III-stage CRC undergoing resection between 2002 and 2018 were included in a retrospective analysis of demographic, clinical, and histology with the aim of defining the impact of LVI on overall survival (OS) and its relationship with other prognostic factors. RESULTS: Overall, 5-year-OS was 62.6% (77-month-median survival). LVI was found in 558 (21%) specimens and resulted associated with 44.9%-5-year-OS (44 months) vs. 64.1% (104 months) of LVI cases. At multivariate analysis, LVI (p = 0.009), T3-4 (p < 0.001), and N ≠ 0 (p < 0.001) resulted independent predictors of outcome. LVI resulted as being associated with older age (p < 0.013), T3-4 (p < 0.001), lower grading (p < 0.001), N ≠ 0 (p < 0.001), mucinous histology (p < 0.001), budding (p < 0.001), and PNI (p < 0.001). Within the LVI + patients, T3-4 (p = 0.009) and N ≠ 0 (p < 0.001) resulted as independent predictors of shortened OS. In particular, N-status impacted the prognosis of patients with T3-4 tumors (p = 0.020), whereas it did not impact the prognosis of patients with T1-2 tumors (p = 0.393). Three groups (T1-2anyN, T3-4N0, T3-4 N ≠ 0), with distinct outcome (approximately 70%-, 52%-, and 35%-5-year-OS, respectively), were identified. CONCLUSIONS: LVI is associated with more aggressive/more advanced CRC and is confirmed as predictor of poor outcome. By using T- and N-stage, a simple algorithm may easily allow re-assessing the expected survival of patients with LVI + tumors.

Surgeon case volume and 5 years survival rate for colorectal cancer.

AIM: Many factors that influence patient outcome in colorectal surgery are not editable, and these are related either the tumor, the patient and the treatment. The surgeon- and hospital-related factors are independent predictors of outcome for colorectal cancer surgery and these are supervision, teaching/training, specialization in colorectal surgery, high caseload, high hospital caseload. MATERIALS OF STUDY: We evaluated the impact of the experience of 4 surgeons on the 5 years survival rate of patients with colon and rectal cancer and we valued if the surgeons' experience plays an equal role in both. RESULTS: Four experienced surgeons operated 384 patients with colorectal cancer. Surgeon with the major experience and colorectal-dedicated presented a slightly better total 5 years survival rate, comparing to other surgeons, although he had a considerably better 5 years survival rate in rectal operations. CONCLUSIONS: We concluded that surgeon- and hospital-related factors directly influence the surgeon learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. A low surgeon or hospital caseload may be compensated by intensified supervision or by improved training and teaching. KEY WORDS: Colon cancer, Colectomy, Surgeon volume.

MRI and correlation between TNM and CEA, CA19.9, AFP in rectal cancer Experience of a single academic surgical center.

In our study we examined 75 patients treated for rectal cancer in the period between 01/01/2011 and 31/12/2014. Out of these 75 patients, we considered those 36 staged through MRI. We then compared the TNM stage obtained through MRI with the one emerged from histological examination. The correlation between the two TNM stages was assessed considering all patients staged through MRI and dividing the cases according to the submission or not to a neoadjuvant treatment. Finally, we analyzed serum levels of tumor markers CEA, CA 19.9 and AFP, relating them with the final disease stage. Data analysis showed a statistically significant correlation in the T stages, especially in the population not subjected to neoadjuvant treatment. Instead, for N, we found no statistically significant correlation. Similarly, none of the tumor markers presented a statistically significant correlation with disease stage. However, according to the positivity of tumor markers, we associated the following score: 0, (no positive marker)1 (only one marker positive) 2 (two markers positive) 3 (three markers positive). In presence of three markers positive, meaning the highest score, we found a statistically significant correlation with N + staging of the disease, obtained by postoperative pathologic examination. The conclusion is that MRI is certainly effective in T stage evaluation. Probably, for limph node involvement evaluation, more reliable parameters for establishing possible lymph node malignancy need to be found. The role of the tumor markers CEA, CA 19.9, AFP during preoperative evaluation of rectal tumors remains undefined. KEY WORDS: MRI, Rectal cancer, Tumor markes, Tumor regression, T stage.

Retrospective survival analysis of stage II-III rectal cancer: tumour regression grade, grading and lymphovascular invasion are the only predictors.

BACKGROUND: Tumour regression grade is gaining interest as a prognostic factor of patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer. METHODS: A series of 68 consecutive patients with locally advanced rectal cancer treated by neoadjuvant chemoradiotherapy and surgery between 2010 and 2016 was retrospectively studied. The impact on disease-free survival (DFS) and overall survival (OS) of several criteria was analysed. Univariate analysis was performed through Kaplan-Meier statistics. Multivariate analysis was performed through Cox regression model. Using criteria found to be related to long-term outcomes, a predictive model of patient's OS was calculated. RESULTS: Poor tumour regression grade - TRG3 (P = 0.010), poor grading - G3 (P = 0.001) and lymphovascular invasion (LVI; P = 0.030) were associated with short OS at univariate analysis. OS was associated with TRG3 and G3 at multivariate analysis (P = 0.016 and P = 0.027, respectively). DFS was associated with LVI (P = 0.001), G3 tumours (P = 0.046) and TRG3 (P = 0.045) at univariate analysis. At multivariate analysis, only LVI was associated with DFS (P = 0.041). A score, pondering the impact of three parameters (2 points for TRG3, 2 for G3 and 1 for LVI), was created and resulted to predict patient OS (P = 0.008), ranging from 94.5 months (score = 0-1) to 32 months (score = 3-5). CONCLUSION: TRG3 and G3 were associated with poor OS, and LVI was the most significant predictor of DFS. An easy-to-use score may allow for a more accurate prediction of OS.

Stage III and Metastatic Lymph Node Ratio Are the only Independent Prognostic Factors in Colorectal Signet-ring Cell Carcinoma Patients.

BACKGROUND/AIM: Signet-ring cell carcinoma (SRCC) is an uncommon histological variant of colorectal cancer (CRC). Knowledge is scarce due to its rarity. Our aim was to better evaluate the clinicopathologic and prognostic features of this little-known malignancy. PATIENTS AND METHODS: Thirty-nine consecutive patients with non-metastatic colorectal SRCC undergoing curative resection at University Hospital of Parma between 2000 and 2018 were examined in this retrospective analysis. RESULTS: Mean overall (OS) and disease-free survival (DFS) were 33.6 and 31.5 months, respectively. At univariate analysis, the lymph-related parameters (nodal status, Stage III, metastatic lymph node ratio and lymphovascular invasion) were significantly associated with shorter OS and poorer DFS. At multivariate analysis, Stage III and a metastatic lymph node ratio ≥25% were found to be the only independent prognostic factors significantly correlated with worse OS and DFS. CONCLUSION: Nodal and lymphatic status should be carefully pondered when planning the most appropriate management of patients with colorectal SRCC.

Rightward shift in colorectal cancer: experience in 1101 patients.

BACKGROUND: In the past decades the right colon cancer showed a higher incidence rate than left colon cancer. This trend is known as "proximal shift" or "rightwards shift." We evaluated rightward shift phenomenon in our region. METHODS: We collected data from 1101 colorectal cancer patients who underwent curative surgery at Parma University Hospital from 01 January 2004 through 01 January 2018. We divided patients into seven subgroups according to the time of surgery to evaluate epidemiological changes through the years of colon cancer. RESULTS: We found a non-linear rightward shift trend of CRC. The incidence of RCC was the 40% between 2004-2005 and 51% in the biennium 2016-2017 (60% in 2012-2013 and 57% in 2014-2015). The patients with RCC were significantly older than patients with LCC. RCCs have poor differentiated tumors. Metastatic disease showed a similar distribution both in left and right CRCs. Peritoneum was the most common metastasis location from right-sided colon cancer. CONCLUSIONS: Data suggest the existence of two different tumor entities in CRC between right-sided colon cancer and left-sided colon cancer. The proximal shift may be a reflection of improved screening programs, diagnostic accuracy and population aging. Ethnicity, gender, diet, environment, and socioeconomic status contribute to CRC incidence and prevalence in different regions.

A comparative analysis between radiation dose intensification and conventional fractionation in neoadjuvant locally advanced rectal cancer: a monocentric prospective observational study.

PURPOSE: The potential role of neoadjuvant radiation dose intensification in locally advanced rectal cancer (LARC) is still largely debated. In the present study, a comparative analysis between radiation dose intensification and conventional fractionation was performed. MATERIALS AND METHODS: In the current prospective observational study (protocol ID RT-03/2011), 56 patients diagnosed with LARC were enrolled between January 2013 and December 2016. More specifically, 25 patients underwent preoperative conventional radiation dose [i.e., 50.4 Gy in 28 fractions here defined as standard dose radiotherapy (SDR)-group 1], whereas 31 patients were candidate for radiation dose intensification (RDI) (i.e., 60 Gy in 30 fractions-group 2). The primary endpoint was the complete pathological response (pCR) rate. Secondary endpoints were postoperative complications and ChT-RT-related toxicity. RESULTS: No statistical significance was observed in pCR rate (20.8% and 22.6% in SDR and RDI group, respectively, p = 0.342). Of contrast, the RDI group showed a significantly higher primary tumor downstaging in case of T3 tumor compared to SDR group (p = 0.049). Sphincter-preserving surgery was 84% and 93.5% in SDR and RDI groups, respectively (p = 0.25). All patients had R0 margins. No surgical-related death was recorded. No statistically significant difference was observed regarding surgical complications and incomplete mesorectal excision. Acute genitourinary toxicity was significantly higher in RDI group (p = 0.015). CONCLUSIONS: The intensification of the neoadjuvant radiotherapy for LARC seems to produce a major pathological response in T3 tumors. The radiation dose intensification appears probably associated with a higher rate of genitourinary toxicity.

Colorectal cancer screenings: a single center experience.

AIM: evaluating the impact of screening programmes on colorectal cancer (CRC) in Italy. METHODS: we studied 1292 patients with colorectal cancer. Data were collected from January 2004 through December 2015 in Parma University Hospital. We compared clinophatological features to evaluate the real impact of screening programmes on detecting early stage colorectal cancers in target population. RESULTS: screening programmes with fecal occult blood test (FOBT) and colonoscopy covered only patients from 50 to 69. In our study we reported that the 52,3% of patients with CRC were over 70 and out of screen time, while only 47,7% were under 70. Early detection seems to be related to early stage of CRC and to an improved overall survival. CONCLUSION: The importance of early detection in colorectal cancers represents the most important outcome for OS. The risk of colorectal cancer is increased in elderly. Actual screening programmes cover less than 50% of population with colorectal cancer. Screening should be considered for patients over 70, due to the high number of new diagnosis in symptomatic disease and worst prognosis, in accordance with advanced cancer stage and comorbidities in elderly.

Intestinal duplications: incidentally ileum duplication cyst in young female.

Gastrointestinal tract duplication is a rare congenital malformation in young patients and in adults, that occur anywhere from the mouth to the anus and their macroscopic structure may be cystic or tubular. Intestinal duplication does not show specific symptoms, indeed they can present with a variety of symptoms including abdominal distension and pain, sickness, hemorrhage, chronic respiratory disorders, as well as non-painful abdominal mass. Nonetheless, intestinal duplication can remain completely asymptomatic and be diagnosed as an incidental finding. Presentation with acute complications such as intestinal invagination or mechanical occlusion is quite rare. We present a case of asymptomatic ileum duplication cyst in young female who referred to the emergency department for trauma and was screened by eco-Focus Assessment Sonography for Trauma (eco-FAST), followed by MR and CT. The patient underwent ileal resection and prophylactic appendicectomy with ileo-cecal termino-lateral anastomosis. In this case, the intestinal duplication cyst was an asymptomatic incidental finding.

Non-surgical complications in oncological colorectal surgery: a comparison between open and laparoscopic techniques.

BACKGROUND: Most of the studies on laparoscopic surgery in the treatment of colorectal cancer analyzed the oncological or surgical outcome. It remains to be clarified, if laparoscopic surgery leads to a significant reduction in the incidence of systemic complications in the postoperative period. MATERIALS AND METHODS: We undertook a quantitative and qualitative assessment of non-surgical complications arising in our patients during the postoperative stay ,in relation to laparoscopic surgery compared to open surgery for colorectal cancer. In the study, 426 patients were recruited. The interventions were performed by an open technique for 225 patients, in VL for 145 patients and 56 patients were subjected to intraoperative conversion. RESULTS: The correlation between surgical technique and onset cardiac complications showed a higher rate of onset of these in open (11.7%) than the VL technique (5.5%). Same result for pulmonary complications (open 13.2%, VL 3.4%) and renal (open 5.7%, VL 1.4%). Average age of patients treated with open surgery 75 years, average operating time duration 169 minutes. Average age patients treated in VL 69 years, average operating time duration 175 minutes. A possible benefit of videolaparoscopic rectal surgery on non-surgical complications has also been investigated, but a significant conclusion has not been reached due to the small number of adverse events found in the reference sample. The evaluation of the duration of the operating session in relation to non-surgical complications showed an increase in the occurrence of pulmonary, renal and systemic adverse events. There was also a significantly greater risk of pulmonary complications in male patients (M 12.7%, F 6.8%). Finally, by stratifying patients by age, a significant positive correlation emerged in the onset of pulmonary complications in the subgroup of patients aged ≥ 70 years, operated with open technique (open 14.6%, vl 3.8). CONCLUSIONS: The data analysed shows a reduction of pulmonary and renal cardiac adverse events after laparoscopic oncological surgery, it has not come to a conclusion for rectal cancer. There is also an increase in adverse events related to the duration of the operating session, the male sex and the age ≥ 70 years, thus enhancing the hypothesis that elderly patients are actually the population who can ultimately benefit more of minimally invasive surgical techniques. KEY WORDS: Adverse eventColectomy, Colorectal cancer, Laparoscopy, Open surgery.

Treatment of postoperative accessory bile duct injury by fibrin glue and balloon tamponade: a case report.

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

The prognostic role of tumor size in patients with gastric cancer.

AIM: The identification of prognostic factors in gastric cancer is important for predicting patients' survival and determining therapeutic strategies. MATERIALS OF STUDY: A retrospective analysis ofpatients who underwent surgery for gastric cancer between 1996 and 2010. The appropriate cut-off value of tumor size related to survival was determined using receiver-operating characteristic (ROC) curves and it was 2,5 cm. Patients were divided into three groups: a small size group (SSG, < 2,5 cm), a medium size group (MSG, between 2,5 and 5 cm) and a large size group (LSG, ≥ 5 cm). RESULTS: Depth of invasion and lymph node metastasis resulted significantly related to tumor size (p < 0.05). Kaplan- Meier survival curves showed that OS rate was significantly higher in SSG patients. The prognosis of patients with tumor size < 2,5 cm was better than patients with tumors ≥ 2.5 cm in size (p < 0.01). DISCUSSION: The tumor size resulted significantly related to OS and it was related to depth of invasion and lymph node metastasis that are themselves prognostic factors. These results confirm and reinforced literature and suggest that at diagnostic pre-operative work-up we can yet define a prognostic value based on tumor size and underline the primary role of complete resection with free surgical margins and D2 lymphadenectomy. CONCLUSION: In patients with gastric cancer tumor size suggests information about the malignancy of the tumor: it is an important predictor of survival and 2,5 cm may be considered as a valid cut-off to define a better or worse prognosis. KEY WORDS: Gastric cancer, Prognosis,Survival, Tumor size.

Gastrointestinal Stromal Tumors: a single Center retrospective 15 years study.

BACKGROUND: Gastro Intestinal Stromal Tumors (GISTs) are defined as mesenchymal tumours that develop within the wall of the gastrointestinal tract. Surgery is the treatment of choice and may be indicated for locally advanced or previously non resectable disease after a favorable response to preoperative therapy with tyrosine kinase inhibitors. METHODS: A retrospective analysis was conducted for all patients with a confirmed or suspected diagnosis of GIST who were admitted to the University Hospital of Parma from January 2000 to January 2015.The following parameters were reviewed and analyzed: age, sex, blood type, symptoms on presentation, tumor site, tumor size, mitotic rate, risk grade, histopathology and immunohistochemistry assays, type of cells. RESULTS: All patients underwent elective surgery. Between January 2000 and January 2015, 61 patients were admitted to the OU General Surgery and Organ Transplantation, University Hospital of Parma and received surgical treatment for GISTs. Thirty-five were male (57.4%) and 26 female (42.6%). The mean age at diagnosis was 69.03 ± 10.07 years (range 29 - 89 years); males 69.6 ± 9.3 years (range 49 - 89 years) and females 68 ± 12.4 years (range 29 - 86 years). Larger tumor size, higher mitotic rate, higher risk rate, margin status contributed to poorer outcome (lower OS and DFS) as independent factors. CONCLUSIONS: Radical surgery is the treatment of choice for resectable GISTs. Very low and low-risk tumor can be treated with surgery alone. KEY WORDS: Gastrointestinal Stromal Tumor, Margin Status, Overall Survival, Tumor size.

Evaluation of surgery risk factor associated to antithrombotic therapy in patients who underwent colorectal surgery.

BACKGROUND: Use of antiplatelet therapy in western people is common. The risk of bleeding related to surgical procedure or invasive procedure is higher.We want to analyse the correlation between colorectal surgery, antiplatelet therapy and postoperative surgical complications. METHODS: We categorized: 176 cases treated for colorectal cancer and we recorded the following data: type of surgery, body max index (BMI), haemoglobin value (Hb); preoperative prothrombin time (PT) and blood transfusions pre and postoperative and during surgery. The analysis focused on two groups: patients who received antiplatelet therapy (AT - antiplatelet therapy) and patients who didn't receive this therapy (NAT - not antiplatelet therapy). RESULTS: In the group of patients who underwent right emicolectomy, haemoglobin values were lower in patients who received antithrombotic therapy than in patients who didn't receive this therapy with a statistical significance (p < 0,05); the same datum resulted in patients who underwent left emicolectomy. Normal weight patients that received antiplatelet therapy had lower values of haemoglobin without statistical significance (p value not significant). Overweight patients who underwent therapy with antiplatelet agents had lesser Hb value than group that didn't performed this therapy (p < 0,05). Patients who received AT showed a bigger percentage of blood transfusions regardless of type of surgery than the second group with statistical significance Normal weight patients showed a different incidence of blood transfusions between patients who underwent antiplatelet therapy (50%) and patients who didn't receive this therapy (29%) with statistic significance (p < 0,05). Overweight patients didn't present this significant difference. We analyzed the incidence of post-operative complications in normal weight patients and overweight patients and we showed that the incidence of complications, both minor and major, was higher in patients who underwent antiplatelet therapy than in the second group regardless of weight CONCLUSIONS: Antiplatelet therapy in patients who underwent invasive surgery changes the incidence of some risk factors, such as bleeding, and of post-operative complications. This result underlines the importance of careful handling and preparation in patients receiving antithrombotic agents that have to undergo invasive surgery. KEY WORDS: Antithrombotic therapy, Bleeding, Colorectal Surgery, Risk factor.

Analysis of indication for laparoscopic right colectomy and conversion risks.

Laparoscopic surgery developed continuously over the past years becoming the gold standard for some surgical interventions. Laparoscopic colorectal surgery is well established as a safe and feasible procedure to treat benign and malignant pathologies. In this paper we studied in deep the role of laparoscopic right colectomy analysing the indications to this surgical procedure and the factors related to the conversion from laparoscopy to open surgery. We described the different surgical techniques of laparoscopic right colectomy comparing extra to intracorporeal anastomosis and we pointed out the different ways to access to the abdomen (multiport VS single incision). The indications for laparoscopic right colectomy are benign (inflammatory bowel disease and rare right colonic diverticulitis) and malignant diseases (right colon cancer and appendiceal neuroendocrine neoplasm): we described the good outcomes of laparoscopic right colectomy in all these illnesses. Laparoscopic conversion rates in right colectomy are reported as 12-16%; we described the different type of risk factors related to open conversion: patient-related, disease-related and surgeon-related factors, procedural factors and intraoperative complications. We conclude that laparoscopic right colectomy is considered superior to open surgery in the shortterm outcomes without difference in long-term outcomes. KEY WORDS: Conversion risks, Indication to treatment, Laparoscopy, Post-operative pain, Right colectomy.

Iatrogenic diaphragmatic hernia following laparoscopic left colectomy for splenic flexure cancer An unusual complication.

Iatrogenic diaphragmatic hernia following laparoscopic left colectomy for splenic flexure cancer. An unusual complication Diaphragmatic hernias are a migration of abdominal structures into the thorax via a diaphragmatic defect; they may be classified as congenital or acquired and acquired hernias can be hiatal, traumatic or iatrogenic, generally complications of thoracic or abdominal surgery. We report a case of iatrogenic diaphragmatic hernia after a laparoscopic left colectomy for splenic flexure tumor; to our knowledge, in literature this case is the first reported. A 51-years-old woman was readmitted to our Hospital on 11th post-operative day for bowel occlusion and a CT - scan revealed left diaphragmatic herniation with fluid dilatation of the small bowel that appeared in the left hemithorax. Laparoscopic surgery resolution was decided and after the reduction of the small bowel in the abdomen we closed the defect using two direct absorbable auto-block hemi-continuous sutures that were covered by a synthetic absorbable mesh. Probably we didn't notice a minimal injury of the left diaphragm caused by ultrasonic scalpel and we can suppose that this delay in presentation may be a result of the gradual enlargement of a microscopic lesion. Patient's gas exchanges were good during surgery and during post-operative course. KEY WORDS: Diaphragmatic hernia, Iatrogenic, Laparoscopy, Left colectomy, Ultrasonic scalpel.

Experience of 463 cases of gastric cancer from a single surgical center.

AIM: To evaluate clinical and histopathological changes of gastric cancer (GC) in the last fifteen years and analyze factors influencing overall survival. MATERIAL OF STUDY: We have retrospectively categorized patients submitted to surgery for GC from January 1996 to December 2010. The analysis focused on two periods: 1996-2003 (period 1) and 2004-2010 (period 2). RESULTS: There was an increase in age distribution of GC in period 2 (p=0.012). Significant increase of whole GC was observed in period 2 (p=0.01). Slight but significant changes in TNM stage were found: in group 2 there was a decrease in the rate of early GC and in advanced depth of tumor invasion; increase of lymph nodes involvement was also demonstrated. Overall survival (OS) had not changed from the first to the second period. There was a significant difference in OS calculated for Lauren histotype: from ten months to surgery, patients with diffuse histotype showed worse prognosis. DISCUSSION: The most important findings were an increase in lymph node involvement and a decrease in depth of tumor invasion, an higher percentage of whole type and a decrease in palliative surgery. Overall-survival hasn't change in the last fifteen years. These results confirms the importance of extent of lymph node dissection in the standard surgical approach of GC, the tumor stage and Lauren histotypes as the main prognostic factors in GC. CONCLUSION: This work confirms the dismal prognosis of GC and the need to increase diagnosis of early gastric cancer. KEY WORDS: Gastric cancer, Lauren histotype, Overall survivall.

Long-term results of preoperative 5-fluorouracil-oxaliplatin chemoradiation therapy in locally advanced rectal cancer.

AIM: To evaluate the activity, safety and long-term survival of patients after preoperative oxaliplatin and 5-fluorouracil chemoradiation therapy in locally advanced rectal cancer (LARC). PATIENTS AND METHODS: Patients with resectable, T3-4 and/or nodal involvement rectal adenocarcinoma were treated with oxaliplatin 60 mg/m(2) weekly and 5-fluorouracil 200 mg/m(2)/d infused continuously for five days, over a period of five weeks, and radiotherapy (45 Gy/25 fractions). The primary end-point was pathological complete response (ypCR). Safety, overall survival (OS) and relapse-free survival (RFS) were secondary end-points. RESULTS: Sixty-six patients were treated. Grade 1-2 diarrhea was the most common adverse event. The ypCR rate was 16.7% (95% confidence interval=7.7-25.7%). After a median follow-up of 73.5 months, 23 patients (34.8%) had experienced relapse. Five-year actuarial RFS and OS rates were 64% and 73%, respectively. Five-year actuarial RFS was 91.7% in the ypCR group versus 57.8% in non-ypCR cases. CONCLUSION: Long-term local control and survival after this very well-tolerated regimen appear encouraging.