Percutaneous cholecystostomy and acute cholecystitis: how, when and why.

AIM: Acute cholecystitis (AC) is one of the most frequent pathologies treated in urgency. An immediate surgical intervention for frail patients who are ineligible for surgery as a result of severe co-morbidities is questionable. The aim of this study is to investigate the safety and the management of percutaneous cholecistostomy (PC) in high-risk surgical patients. MATERIALS AND METHODS: In the period of time January 2015 - May 2021 we observed 1105 patients admitted with acute cholecystitis in our Department. In the group with severe cholecystitis (160 patients, 14.48%), 137 (12.39%) were submitted to immediate surgery, and 23 (4.8%) were treated with PC. All these patients were non-responding to conservative management. Initially, we used PC as a definitive treatment; from the second half of 2018 PC was implemented as a bridge to surgery. RESULTS: Clinically, symptoms resolved in all the 23 patients. Mortality was nihil and no complication was recorded. PC was used as definitive treatment in 14 cases, wheres in 9 patients PC was intended as a-bridge-to-surgery treatment, and was followed by cholecystectomy. DISCUSSION: 2017 guidelines, of World Society of Emergency Surgery recommended PC as a safe and effective management of AC in patients with multiple comorbidities. In this group of patients PC achieves a prompt resolution of clinical symptoms and is superior to conservative management. There are no absolute contraindications to PC. CONCLUSIONS: PC is a safe and less invasive treatment of AC for patients with prohibitive surgical risk. It may be used as bridge to surgery to switch high-risk for moderate-risk patients, more suitable for a safe and definitive surgical treatment. KEY WORDS: Acute cholecystitis, High-risk surgical patients, Percutaneous cholecystostomy.

Hypofractionation and Concomitant Boost in Ductal Carcinoma In Situ (DCIS): Analysis of a Prospective Case Series with Long-Term Follow-Up.

We previously reported on a cohort of breast cancer patients affected with ductal carcinoma in situ (DCIS) that were treated with breast conservative surgery and hypofractionated whole-breast radiotherapy with a concomitant boost to the lumpectomy cavity. We now report on the long-term results of the oncological and toxicity outcomes, at a median follow-up of 11.2 years. We also include an analysis of the predictive factors for local recurrence (LR). Eighty-two patients with long-term observation were considered for this report. All received hypofractionated post-operative radiotherapy with a concomitant boost (45 Gy/20 fractions to the whole breast and 50 Gy/20 fractions to the lumpectomy cavity). We report on LC rates at 5 and 10 years, overall survival (OS), and breast-cancer-specific survival (BCSS), employing the Kaplan-Meier method. Cox proportional regression analysis was used to determine the role of selected clinical parameters on the risk of local recurrence, by the univariate and multivariate models. After a median follow-up of 11.2 years (range 5-15 years), 9 pts (11%) developed LR. The LR rates at 5 years and 10 years were 2.4% and 8.2%, respectively. The 5- and 10-year overall survival rates were 98.8% and 91.6%, respectively. The 5- and 10-year breast-cancer-specific survival rates were 100.0% and 99.0%. Late skin and subcutaneous toxicities were generally mild, and cosmetic results were good-excellent for most patients. For the univariate regression analysis, ER positive status (HR; 95% CI, p = 0.021), PgR positive status (HR; 95% CI, p = 0.012), and the aggregate data of positive hormonal status (HR; 95% CI, p = 0.021) were inversely correlated to LR risk. Conversely, a high tumor grade (G3) was directly correlated with the risk of LR (HR; 95% CI, p = 0.048). For the multivariate regression analysis, a high tumor grade (G3) confirmed its negative impact on LR (HR 0.40; 95% CI 0.19-0.75, p = 0.047). Our long-term data demonstrate hypofractionated whole-breast radiotherapy with a concomitant boost to be feasable, effective, and tolerable. Our experience suggests positive hormonal status to be protective with respect to LR risk. A high tumor grade is a risk factor for LR.

Morbidity and mortality analysis in general surgery operations. Is there any room for improvement?

BACKGROUND: The aim of this work is to examine the performance of surgeries, by evaluating the results. The evaluation of the results, with particular attention to complications, is the corner stone to identify the causes leading to correction of any predisposing factors and reducing risks, to improve quality of care. METHODS: We performed a retrospective analysis of 952 consecutive patients who had elective or emergency surgery from November 1, 2018, to October 31, 2019. We classified surgical intervention according to their complexity. The Clavien Dindo classification was used to categorize the complications. We performed a stepwise multivariate logistic-regression analysis, with the presence of postoperative complications as dependent variable and age, gender, BMI, ASA, type of surgery procedures, complexity of surgery, operative time as covariates. RESULTS: A total of 952 surgical procedures were included in this study. Abdominal procedures were the most frequent type of surgery performed (52.1%). Postoperative complications occurred in 120 surgical procedures (12.6%), these are related to the increase of the ASA score and the longer average operative time, with an increase of developing complication of 5% for each additional 10 minutes of surgery. CONCLUSIONS: Many factors influence postoperative morbidity and mortality. Particular attention was due to complication's evaluation, about all in abdominal surgery and high complexity procedures. We argue that key factors which influence the favorable surgical outcome are compliance with standardized safety procedures, volume of activity of the structure, presence of interdisciplinary care groups, and ability of health professionals in recognizing and promptly treating complications.

Ideal level of ligation of the inferior mesenteric artery. An old debate for a current surgical approach.

AIM: The ideal level of ligation of the inferior mesenteric artery (IMA) during resection for colorectal cancer is still controversial. The aim of this study was to demonstrate the real advantages and, above all, the adequacy of oncological staging after a low ligation of the IMA with additional LN retrieval in patients undergoing surgery for colorectal cancer. MATERIALS AND METHODS: Between January 2013 and December 2020, 157 patients who underwent curative resection of a primary colorectal tumor were retrospectively included: 64 patients underwent high ligation of the IMA and 93 patients underwent low ligation of the IMA with additional LN retrieval. Results - Mean number of lymphnodes harvested (the median number of harvested nodes was 16.2 in "high ligation" group vs 15.4 in "low ligation" group), operation time (272 minutes vs 293 minutes), intraoperative blood loss (40 cc vs 53 cc) and recovery time (median postoperative hospitalization was 6.4 days in both groups) were not significantly different between the groups. DISCUSSION: High ligation of the IMA preserves an adequate length of the colon to perform a successful anastomosis and facilitates apical LN dissection. However, it may be associated with an increased risk of anastomotic leakage. Low ligation of the IMA is less invasive and it is associated with a better preservation of genitourinary function and, futhermore, with an accurate oncological clearance. CONCLUSION: Low ligation of the IMA with additional LN retrieval might be an oncologically safe and less invasive procedure in the surgical management of patients with colorectal cancer. KEY WORDS: Colorectal cancer, Inferior mesenteric artery, Ligation.

Blunt splenic trauma 2.0. State of the art.

AIM: To evaluate the advantages and potential risks of "Non Operative Management" (NOM) in order to redifine the technique into the true gold standard and to extend its application to the emergency care of blunt splenic trauma. MATERIALS AND METHODS: Blunt trauma cases treated between 2004 and 2019 have been retrospectively evaluated. Every patient has been distributed at the hospital admission in 3 different groups: stable, unstable and transient responder according to ATLS. NOM exclusion criteria were only introduced in 2013: we therefore assessed datas before and after this year. RESULTS: Over a period of 15 years, approximately 6 patients per year were admitted to our hospital with a spleen injury. After the introduction of the NOM protocol in 2013, the proportion of splenectomies progressively decreased. This rate also increased for higher injury grades. The overall number of patients who underwent NOM was 40 (43%), but while between 2004 and 2012 only 25% of patients were managed with NOM, between 2013 and 2019 70.3% of patients were treated with NOM. CONCLUSIONS: Nowadays any blunt splenic trauma could, theoretically, undergo NOM, regardless of the grade of the injury; the only strict criteria for OM should be haemodynamic instability; this assumption depends, of course, on hospital's human and technological resources. KEY WORDS: Non operative management, Splenic trauma, Splenectomy.

Correction to: Ten-year results of accelerated hypofractionated adjuvant whole-breast radiation with concomitant boost to the lumpectomy cavity after conserving surgery for early breast cancer.

An error inadvertently occurred in the discussion of the original publication when citing the local relapse rates of the EORTC 22881-10882 trial ('boost vs no boost trial').

A proposal for thyroid surgery: criteria to identify the references of endocrine surgery.

Indicators of effectiveness and quality of care are needed to improve the outcomes in many surgical fields. International and national studies in thyroid surgery have not clearly documented an association between number of cases and outcome quality, but it is essential for the figure of a highly experienced surgeon, able to provide proof of positive outcomes. Therefore, we try to underline the structural and technical requirements in thyroid surgery. Moreover, the need for an accreditation program is outlined.

Ten-year results of accelerated hypofractionated adjuvant whole-breast radiation with concomitant boost to the lumpectomy cavity after conserving surgery for early breast cancer.

Accelerated hypofractionated whole-breast radiotherapy (WBRT) is considered a standard therapeutic option for early breast cancer (EBC) in the postoperative setting after breast conservation (BCS). A boost to the lumpectomy cavity may further increase local control. We herein report on the 10-year results of a series of EBC patients treated after BCS with hypofractionated WBRT with a concomitant photon boost to the surgical bed over 4 weeks. Between 2005 and 2007, 178 EBC patients were treated with a basic course of radiotherapy consisting of 45 Gy to the whole breast in 20 fractions (2.25 Gy daily) with an additional boost dose of 0.25 Gy delivered concomitantly to the lumpectomy cavity, for an additional dose of 5 Gy. Median follow-up period was 117 months. At 10-year, overall, cancer-specific, disease-free survival and local control were 92.2% (95% CI 88.7-93.4%), 99.2% (95% CI 96.7-99.7%), 95.5% (95% CI 91.2-97.2%) and 97.3% (95% CI 94.5-98.9%), respectively. Only eight patients recurred. Four in-breast recurrences, two axillary node relapses and two metastatic localizations were observed. Fourteen patients died during the observation period due to other causes while breast cancer-related deaths were eight. At last follow-up, ≥G2 fibrosis and telangiectasia were seen in 7% and 5% of patients. No major lung and heart toxicities were observed. Cosmetic results were excellent/good in 87.8% of patients and fair/poor in 12.2%. Hypofractionated WBRT with concomitant boost to the lumpectomy cavity after BCS in EBC led to consistent clinical results at 10 years. Hence, it can be considered a valid treatment option in this setting.

Does accelerated hypofractionated adjuvant whole-breast radiotherapy increase mammographic density or change mammographic features?

OBJECTIVE: To compare mammographic features before and after accelerated hypofractionated adjuvant whole-breast radiotherapy (AWB-RT) and to evaluate possible appearance of modifications. METHODS: A retrospective review of 177 females before and after an AWB-RT treatment (follow-up ranging from 5 to 9 years) was performed by four radiologists focused in breast imaging who independently evaluated diffuse mammographic density patterns and reported on possible onset of focal alterations; modifications in density and fibrosis with parenchymal distortion were deemed as indicators of AWB-RT treatment impact in breast imaging. RESULTS: Prevalent mammographic density (D) patterns in the 177 females evaluated were according to the American College of Radiology-Breast Imaging Reporting and Data System (ACR-BIRADS): D1, fibroadipose density (score percentage from 55.9% to 43.5%); and D2, scattered fibroglandular density (from 42.9% to 32.7%). No change in diffuse mammographic density and no significant difference in mammographic breast parenchymal structure were observed. "No change" was reported with score percentage from 87% to 79.6%. Appearance of fibrosis with parenchymal distortion was reported by all radiologists in only two cases (1.1%, p = 0.3); dystrophic calcification was identified with percentage score from 2.2% to 3.3% (small type) and from 9.6% to 12.9% (coarse type). CONCLUSION: No statistically significant changes in follow-up mammographies 5-9 years after AWB-RT were detected, justifying large-scale selection of AWB-RT treatment with no risk of altering radiological breast parameters of common use in tumour recurrence detection. ADVANCES IN KNOWLEDGE: The hypofractionated radiotherapy (AWB-RT treatment) is a new proven, safe and effective modality in post-operative patients with early breast cancer with excellent local control and survival. In our study, the absence of changes in mammographic density patterns and in breast imaging before and after AWB-RT treatment (up to 5-9 years after radiotherapy) justifies large-scale use of AWB-RT treatment without hindrance in tumour recurrence diagnosis.

Post-thyroidectomy chronic asthenia: self-deception or disease?

There is clinical evidence that post-total thyroidectomy (TT) patients can present persistent asthenia. The aim of this study was to evaluate the prevalence of asthenia symptoms in such patients, assess whether a chronic asthenia syndrome could be caused by TT or become evident after it. An observational study was carried out comparing two groups of 100 patients each, all with homogeneous characteristics. Group A was treated with total lobectomy (TL), Group B with TT. All patients presented normal thyroid hormone levels. The patients were interviewed in order to identify the ones affected by post-operative asthenia persisting for at least six months, with reduced ability to perform physical and mental work, not showing improvement with rest. The severity of the symptoms has been measured by means of the brief fatigue inventory (BFI). Statistical analysis was performed to evaluate statistically significative differences between groups and prognostic factors in TT group. The incidence of post-operative asthenia was 0 % after TL and 25 % after TT, with the operation being the only significant variable. Asthenia is well known as symptom of post-thyroidectomy, but it has not been adequately investigated as consequence of surgery. We demonstrated that the complete removal of the thyroid gland could determine chronic post-thyroidectomy asthenia, although with intensity limited to low/moderate. Post-thyroidectomy asthenia is a relevant sequela interfering with quality of life of at least 25 % of patients operated, suggesting the need to identify its real causes and limit the indication to TT only when strictly required.

Hypofractionation and concomitant boost to deliver adjuvant whole-breast radiation in ductal carcinoma in situ (DCIS): a subgroup analysis of a prospective case series.

To report the four-year outcomes of accelerated hypofractionated whole-breast radiotherapy (WBRT) with a concomitant boost (CB) to the tumor bed in ductal carcinoma in situ (DCIS), we performed a subgroup analysis of 103 patients affected with DCIS within a cohort of 960 early breast cancer patients treated with breast conservation and hypofractionated WBRT. Prescription dose to the whole breast was 45 Gy (2.25 Gy/20 fractions) with an additional daily CB of 0.25 Gy to the surgical cavity (2.5 Gy/20 fractions up to 50 Gy). With a median follow-up of 48 months (range 12-91), no local recurrence was observed. Maximum detected acute skin toxicity was as follows: G0 in 35 % of patients, G1 in 54 %, G2 in 9 % and G3 in 2 %. Late skin and subcutaneous toxicity were generally mild with only 1 % of patients experiencing ≥G3 events (telangiectasia). No major lung and heart toxicity were detected. Cosmetic results were excellent in 50 % of patients, good in 37 %, fair in 9 % and poor in 4 %. Quality of life had a generally favorable profile both within the functioning and symptoms domains. The present result supports the hypothesis that DCIS patients could be safely treated with a hypofractionated schedule employing a CB to the lumpectomy cavity.

Five-year results of a prospective case series of accelerated hypofractionated whole breast radiation with concomitant boost to the surgical bed after conserving surgery for early breast cancer.

Accelerated hypofractionation (HF) using larger dose per fraction, delivered in fewer fractions over a shorter overall treatment time, is presently a consistent possibility for adjuvant whole breast radiation (WBRT) after breast-conserving surgery for early breast cancer (EBC). Between 2005 and 2008, we submitted 375 consecutive patients to accelerated hypofractionated WBRT after breast-conserving surgery for EBC. The basic course of radiation consisted of 45 Gy in 20 fractions over 4 weeks to the whole breast (2.25 Gy daily) with an additional daily concomitant boost of 0.25 Gy up to 50 Gy to the surgical bed. Overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS) and local control (LC) were assessed. Late toxicity was scored according to the CTCAE v3.0; acute toxicity using the RTOG/EORTC toxicity scale. Cosmesis was assessed comparing treated and untreated breast. Quality of life (QoL) was determined using EORTC QLQ-C30/QLQ-BR23 questionnaires. With a median follow-up of 60 months (range 42-88), 5 years OS, CSS, DFS and LC were 97.6, 99.4, 96.6 and 100 %, respectively. Late skin and subcutaneous toxicity was generally mild, with few events > grade 2 observed. Cosmetic results were excellent in 75.7 % of patients, good in 20 % and fair in 4.3 %. QoL, assessed both through QLQ-C30/QLQ-BR23, was generally favorable, within the functioning and symptoms domains. Our study is another proof of principle that HF WBRT with a concurrent boost dose to the surgical cavity represents a safe and effective postoperative treatment modality with excellent local control and survival, consistent cosmetic results and mild toxicity.

[Neurendocrine tumours of the appendix, colon and rectum: current surgical aspects]. / Attualità nella chirurgia dei tumori neuroendocrini dell'appendice, del colon e del retto.

Neuroendocrine tumours (NET) are a heterogeneous group of neoplasms deriving from a system of diffuse neuroendocrine cells in organs and tissues, defined as the "diffuse neuroendocrine system". Over the period from 1996 to 2005 42 patients with gastroenteropancreatic (GEP) NET were observed (M.F ratio: 1.5:1; mean age 58 years; > 60 years for all localisations except the appendix [< 39 years]). Twenty-three were tumours of the appendix, colon and rectum, corresponding to 55% of all those affecting the digestive tract: 8 appendix (35%), 6 right colon (26%), 4 left colon (17%) and 5 rectum (22%). The NET diagnosis was formulated in all cases on the basis of histological and immunohistochemical examinations. The mean follow-up period was 5 years (range: 1-10). In the RO-RI cases no relapses occurred and those who were not disease-free were treated with somatostatin analogues and/or chemotherapy. NET of the appendix, colon and rectum are rare, despite being the most frequent among the GEP tumours, and are difficult to diagnose, and therefore sometimes pose problems of surgical therapy, which, when performed in time, may be curative. NET of the appendix measuring <2 cm, localised in the distal part without local infiltration, can be treated by simple appendicectomy and removal of the mesenteriole; otherwise, right hemicolectomy is indicated. The surgical treatment of tumours of the colon, except for well differentiated cases measuring <2 cm with a pedunculate structure such as to allow safe endoscopic removal, consists in radical hemicolectomy with lymphadenectomy. Carcinoids of the rectum measuring <1 cm and 1 cm to 2 cm, in the absence of other negative prognostic factors, can be treated locally by transanal endoscopic microsurgery (TEM) or minimally invasive transanal surgery (MITAS). Tumours measuring >2 cm or presenting muscular invasion and/or lymph-node metastases (malignant carcinoids), regardless of tumour diameter, are submitted to radical operations, as in the case of carcinoma of the rectum. Extensive disease which is no longer curable with surgery alone is treated with chemotherapy and bio-chemotherapy, but it is above all treatment with somatostatin analogues that plays a major role in symptom control.