The influence of residents in the outcome of elective laparoscopic surgery: a prospective study comparing a teaching hospital and a private community hospital in Italy.

OBJECTIVES: We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents. MATERIALS AND METHODS: The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay. RESULTS: The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type. CONCLUSIONS: Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Challenging differential diagnosis between lipoma and well-differentiated liposarcoma in the retroperitoneum. A case report.

Liposarcomas are the most common type of sarcomas arising in the retroperitoneum. Retroperitoneal lipomas are extremely rare. They should be distinguished from well-differentiated liposarcomas in order to provide the appropriate treatment. A 53-years-old male was admitted with the presence of a palpable mass in the upper abdomen. Contrast enhanced computerized tomography (CT) of the abdomen and pelvis showed a 20x12 cm mass arising in the retroperitoneum and inglobing the celiac and superior mesenteric trunks. Because of unresectability an open surgical biopsy was performed. Histological examination showed the presence of adipose tissue with diffuse liponecrosis without definitive features of neoplasia. At six-month follow-up a CT documented an increase of the tumor to 22x13 cm. The mass was stable at the CT, performed at 1-year follow-up. Given the impossibility to distinguish well-differentiated liposarcomas from lipomas and the in the present case of unresectable retroperitoneal mass, an observational follow-up was a justified.

[Treatment of mild malnutrition and reduction of morbidity in major abdominal surgery: randomized trial on 153 patients]. / Trattamento della malnutrizione lieve e riduzione delle compli- canze in chirurgia addominale maggiore: studio randomizzato su 153 pazienti.

OBJECTIVES: Severe malnutrition (defined as weight loss more than 10% in a period of six months) is considered an important risk factor in major abdominal surgery, because of a higher post-operative mortality and morbidity. The aim of our study is to assess the role of mild malnutrition (weight loss low than 10% in a period of six months) as a risk factor in major abdominal surgery and to evaluate the efficacy of therapy in order to improve outcomes in terms of in-hospital mortality, length of hospital stay and post-operative complications. Moreover, we evaluated serum albuminemia and lymphocyte count, important nutritional index, as predictive risk factors. MATERIALS AND METHODS: We performed a randomized prospective trial, and admitted in our institution 153 adult patients, 43 with mild malnutrition and 110 without. The malnourished patients were randomized in two groups: the first one received oral immunonutrition (Impact Oral) for 7-10 days before surgery (22 pz), the second one received no nutritional support. RESULTS: We observed a higher number of complications in the non-treated malnourished patients (57%) versus both the treated malnourished patients (13.6%) and the normal group (19%) (p<0.001). Increased morbidity was observed in patients with serum albuminemia <2.8 gr/dl (69.2%) and with lymphocyte count <1.500 mm3 (57%). CONCLUSIONS: Nutritional enriched support demonstrated his efficacy in reducing morbidity, and length of hospital stay. Pre-operative oral immunonutrition might be suggested and established in all the patients with mild malnutrition that will be operated on major abdominal surgery.

[Breast scintigraphy with technetium 99m sestamibi, as support to radiologic methods in the study of breast lesions]. / Scintigrafia mammaria con 99mTc-SESTAMIBI, come supporto alle metodiche radiologiche nello studio delle lesioni mammarie.

Our study was aimed at investigating the efficacy of scintigraphy with 99mTc-Sestamibi (MIBI) as a support to mammography and US in the diagnosis and staging of breast cancer. Twenty-seven women with breast lesions were examined: the masses, detected at mammography and US, ranged in diameter 0.7 to 2.5 cm; mass features suggested a benign lesion in 5 patients, a malignant lesion in 9 patients and a questionable diagnosis in 13 patients. 99mTc-MIBI scintigraphic images were analyzed blind by two observers and the pattern was considered positive when tracer uptake was demonstrated at the lesion. In neoplastic lesions, tracer uptake was looked for also in the axilla. All the patients were submitted to surgery and, in case of malignancy, lymphadenectomy was also performed. MIBI scintigraphy was negative in 14/16 benign lesions and positive in 9/11 malignant lesions. Tracer uptake in the axilla was observed in 3 of 5 patients with nodal involvement. Scintigraphy had 82% sensitivity, 87% specificity and 85% accuracy in the diagnosis of breast cancers.

Aneuploid polyclonality in image analysis.

Solid tumors such as colorectal adenocarcinomas consist of biologically diverse cell subpopulations. Nuclear DNA content of tumor cells in colorectal carcinomas may be studied with different techniques of intranuclear DNA quantification. In the current study, the DNA ploidy of samples obtained from 68 patients with colorectal carcinoma (age ranging from 46 to 86 years, mean age 66 years), treated with radical surgery, between the years 1992 and 1995 was analyzed. DNA ploidy was assessed using a CAS 200 image analyzer and was evaluated on neoplastic tissue and undamaged healthy mucosa obtained from the edges of the surgical resection. Approximately 150-300 cells were analyzed for each sample. The aim of this study was to evaluate the prognostic significance of the polyclonal cases correlated with lymph node infiltration and disease free-survival. The pathological stage according to the TNM classification was compared to ploidy: an increase in multiple stemlines was observed in stage III cases, i.e., a progression towards aneuploidy and multiple stemlines was significantly associated with lymphatic metastasis (p<0.0003). Concerning distant metastasis, we found a correlation between stage IV and polyclonality. A significant correlation was observed between disease-free survival and aneuploid and polyclonal cases (p<0.0053). In polyclonal cases a nine fold greater relapse risk compared to the non-polyclonal cases was observed (p<0.0004). In two cases, the adeno-carcinoma of the sigma was polyclonal and its hepatic metastasis contained the predominant aneuploid clone with the same cytometric characteristics (DNA index) of the original lesion.

Critical evaluation of the anastomoses in large bowel surgery: experience gained in 533 cases.

We critically examined the morbidity and mortality of manual and stapled colorectal anastomosis in a retrospective study of 533 patients who underwent colorectal resection for neoplastic and non-neoplastic disease. The clinically detected anastomotic dehiscence rate was 4.5%, and the mortality rate 1.8%. The extraperitoneal site of the anastomosis after rectal anterior resection with stapled anastomosis and surgery for cancer showed a statistically significant predisposition to anastomotic dehiscence. Age, emergency surgical intervention, curative versus palliative resection, the location of the anastomosed intestinal segments, type of anastomosis and presence of a protective colostomy did not appear to be statistically significant factors for anastomotic dehiscence. While the stapler may offer an advantage in the individual case, the low incidence of morbidity and mortality for manual anastomosis in this study reaffirms the soundness and importance of the manual colorectal anastomosis in the surgeon's technical armamentarium.

[Use of surgical staplers in proctocolectomy with ileal pouch. Effects on immediate results]. / L'impiego delle suturatrici meccaniche nella proctocolectomia con pouch ileale. Influenza sui risultati immediati.

The immediate results of 37 restorative proctocolectomies are reported comparing morbidity of stapled vs manual procedures. The stapled technique is easier and faster but does not reduce the incidence of leakages and pelvic sepsis related to the ileal pouch. It seems, though, to be more useful in reducing the morbidity related to the ileoanal anastomosis.

Extended resection in the treatment of colorectal cancer.

Between 1975 and 1990, 525 patients underwent resection of colorectal cancer in our unit. Of these, 38 had tumour invading adjacent structures and underwent an extended resection. Overall, there were 67 cases treated palliatively. Of these, three were in the group of 38 having an extended resection. When the groups of radical not extended (n = 423) and radical extended resections (n = 35) were compared, respective values for mortality (1.9% vs 0) and morbidity (12.8% vs 11.3%) were not different. Respective local recurrence rates (13% vs 26%) were significantly greater after extended resection. Five-year survival after extended resection was 30%, no different from the general survival rate for standard resections for T2-3 node-positive tumours. Extended resection is thus a safe and important approach for locally advanced tumours.

Surgical treatment of epiphrenic diverticula of the esophagus: is diverticulectomy always necessary? A report of two cases.

Two cases of epiphrenic esophageal diverticula are reported. The surgical treatment was limited to the correction of the associated motor disorder, namely gastroesophageal reflux without diverticulectomy.

[Treatment of pancreatic pseudocysts]. / Traitement des pseudokystes du pancréas.

Based on the results of treatment of a personal series of 13 cases of pseudocyst of the pancreas, between 1974 and the present day, it is suggested that the choice of therapy should be surgical. An internal shunt is preferred for pseudocysts as a result of acute pancreatitis or injury, whereas a wider cysto-wirsung jejunostomy is recommended for cysts developing during the course of chronic pancreatitis. These proposals follow analysis of immediate and long-term (mean: 51 months) follow-up, on the basis of mortality, morbidity, pain symptoms, malabsorption and postoperative diabetes.

Enterogenous reduplication cyst of the pancreas. A case report.

A case of enterogenous cyst of the head of the pancreas is reported. The cyst was shown to be endowed with both secreting and absorbing intestinal epithelium. The surgical treatment consisted in the removal of the whole cyst. The approach to be followed in the case of this extremely rare disease is briefly discussed, underlining that the present is the third such case to date reported in the literature.