Lessons learned from 227 biological meshes used for the surgical treatment of ventral abdominal defects.

PURPOSE: The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients. METHODS: A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016. RESULTS: A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%). CONCLUSIONS: Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

[Long-term results of neoadjuvant radiochemotherapy in squamous carcinoma of the thoracic esophagus]. / Risultati a lungo termine del trattamento chemio-radioterapico neoadiuvante del carcinoma squamoso dell'esofago toracico.

AIM: Surgery is considered the mainstay of therapy for clinically resectable esophageal cancer, even though neoadjuvant treatments are frequently added. The aim of this study was to analyse our experience on neoadjuvant treatment of squamous cell carcinoma of the thoracic esophagus with special reference to long-term METHODS: The results of 66 patients who underwent neoadjuvant chemo-radiotherapy for squamous cell carcinoma of the thoracic esophagus at the 1(st) Division of General Surgery, University of Verona, from February 1995 to December 2002 were analysed statistically. The median follow-up period for the surviving patients was 65.3 months. RESULTS: The induction treatment was completed in 93.9% of cases, with a null treatment related mortality and a complication rate of 34.8%. Sixty-one out of the 66 patients (92.4%) underwent resection with a R0-resection rate of 83.9%. A major pathological response (responders) was gained in 42.6% of the cases, with a complete response (pTONO) observed in 29.5% of the cases. Overall 5-year survival for the 66 patients was 30%, while the 5-year survival rate raised to 43% in R0-patients. A better long-term survival was observed for responders with respect to ''non-responders'' with a 5-year survival rate of 70% and 13%, respectively (P<0.001). CONCLUSIONS: This neoadjuvant protocol regimen represents a feasible treatment with an acceptable morbidity. The tumor efficacy in term of pathological responses was similar to literature RESULTS: An high rate of R0-resections was achieved with a possibility of cure limited to this group of patients. A better long-term survival was observed in patients with major pathological responses.

Endoscopic ultrasonography in the staging of esophageal carcinoma after preoperative radiotherapy and chemotherapy.

BACKGROUND: In past years multimodal neoadjuvant treatment for carcinoma of the esophagus has been used with increased frequency. Staging of the neoplasm still remains fundamental in evaluating the response to therapy and in planning operation. The aim of the present study was to assess the accuracy of endoscopic ultrasonography (EUS) in a group of patients with squamous cell carcinoma of the thoracic esophagus after undergoing radiotherapy and chemotherapy. METHODS: Among a group of 111 patients with squamous cell carcinoma of the thoracic esophagus and treated with preoperative radiotherapy and chemotherapy, 87 were operated. In these patients it was possible to compare the results of EUS, with regard to depth of invasion of esophageal wall (T) and lymph node involvement (N), with the results of operation and histopathologic study. RESULTS: Feasibility of EUS before and after neoadjuvant treatment was 71.2% and 83.9%, respectively. The overall accuracy of EUS regarding the wall invasion was 47.9%. The more frequent error was overstaging, especially in patients with complete response and in patients with minimal residual disease. In the assessment of lymph node involvement, EUS showed an overall accuracy of 71.2% with a moderate kappa value. Sensitivity for N1 and NO was 73.7% and 68.6%, respectively. CONCLUSIONS: Endoscopic ultrasonography was feasible in most patients after preoperative radiotherapy and chemotherapy, but our study documented a worsening of accuracy of EUS in the evaluation of T attributable to the confounding presence of radiation fibrosis and soft tissue reaction after radiotherapy and chemotherapy.

Induction therapy for squamous carcinoma of thoracic esophagus.

From June 1987 to March 1992, 70 patients with squamous cell carcinoma of the esophagus were entered into a treatment protocol that included a preoperative course of radiotherapy (3,000 cGy) and chemotherapy (cisplatin and 5-fluorouracil). The preoperative therapy was well tolerated. Forty-nine of these patients underwent esophageal resection (total or subtotal) and 6 patients died subsequently (12.2%). The morbidity was not dramatically affected by preoperative treatment. Histopathologic studies showed no residual disease in the resected specimen of 11 patients (19.2%), only some residual microscopic clusters of neoplastic cells in 8 patients (14%) and macroscopic cancer in the remaining patients (66.8%). The estimated overall Kaplan-Meier survival at 1, 2, and 3 years was 53.6%, 28.6%, and 21.5%, respectively. Our study, like other reports, demonstrates an improved survival in the group of patients who had a complete response after radiotherapy or chemotherapy (p = 0.002). Moreover, the lack of diagnostic procedures to evaluate the presence of residual tumor after radiotherapy and chemotherapy, suggests that only surgical resection can provide an accurate prognostic information and a complete treatment.

Acute cholecystitis: ultrasonographic staging and percutaneous cholecystostomy.

Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.

Primary carcinoma of the hypopharynx and cervical esophagus: evolution of surgical therapy.

Carcinoma of the cervical esophagus is invariably fatal because of its advanced stage at presentation. In our surgical division, 167 patients with primary squamous-cell carcinoma of the cervical esophagus were treated over the period between 1973 and June 1992. The tumor was localized in the cervical esophagus in only 37 cases, whereas it also involved the hypopharynx in 112 patients or extended to the cervico-thoracic segment in the remaining 18 subjects. Ninety-three patients underwent surgery (operability rate: 55.6%), and in 68 of these the tumor was resected (resectability rate: 73.1%). Over the 20-year study period, surgical techniques have evolved as a result of the experience gained with previous surgical therapies. Six of the 68 resected patients died (8.8%). Ten patients undergoing surgical resection subsequently presented with local recurrence: 3 after cervical esophagectomy (25%) and 7 after total esophagectomy (12.5%). Moreover, six patients treated by radical resection without laryngectomy had recurrent tumor (46.1%). The cumulative 5-year survival rate was 16.6%. The experience accumulated over the years suggests that the procedure of choice is laryngopharyngo-(total)-esophagectomy without thoracotomy, with gastric pull-up for reconstruction of the digestive tract. The other surgical procedures, in our experience as well in that of other authors, are associated with a higher incidence of relapse and a decreased survival rate. In an attempt to improve on the disappointing long-term results, we introduced a preoperative course of chemotherapy and radiotherapy in the management of the last 6 patients in our series.(ABSTRACT TRUNCATED AT 250 WORDS)

Vater's papilla and periampullary area villous adenoma: personal experience about nine cases and review of the literature.

Villous tumor of the duodenum is a rare disease. The authors report their personal experience from 1987 to 1993 with nine cases of duodenal villous tumors. The treatment was pancreatoduodenectomy in four cases, segmental resection of the duodenum in two cases and submucosal excision in three cases. The authors review the literature of the last 15 years in which only 241 cases of duodenal villous tumors are reported; in this review the clinical, diagnostic and therapeutic characteristics of the disease are analyzed. This malignancy presents peculiar characteristics for histologic diagnosis and pathology classification. For this reason, even surgical treatment deserves careful reflection to guarantee a curative procedure and to formulate a positive prognosis.

Aneurysm of the celiac trunk: diagnosis with US-color-Doppler. Presentation of a new case and review of the literature.

Aneurysms of the celiac trunk are the rarest forms of aneurysms of the visceral arteries. Since 1958, when Schumaker reported the first case to be successfully treated surgically, only 69 cases have been reported in the international literature. The detection of such aneurysms, which are often asymptomatic, is mostly occasional. Approximately 15-20% of cases may be complicated by rupture with a mortality rate of around 80%. This eventuality makes surgical treatment mandatory even in asymptomatic cases. The authors report on their experience with the surgical treatment of one case of aneurysm of the celiac trunk and then go on to review the relevant literature.

Extraintestinal infection by group C Salmonella: a case report and review of the literature.

Infected or mycotic aneurysms of the aorta are not very frequent but they are associated with high morbidity and mortality rates. Vascular infections due to Salmonella are not very frequent, but in recent years the reports of infections of this type have been on the increase. The authors report their experience with a case of aneurysm of the abdominal aorta infected by group C Salmonella and go on to review the literature on the subject.

Efficacy and toxicity of vinorelbine-carboplatin combination in the treatment of advanced adenocarcinoma or large-cell carcinoma of the lung.

AIMS AND BACKGROUND: The aim of the study was to assess the activity and toxicity of the vinorelbine-carboplatin combination in advanced adenocarcinoma or large-cell carcinoma of the lung. The new vinca derivative, vinorelbine, shows promising activity when combined with cisplatin, but toxicity of the combination is substantial. METHODS: Accordingly, we substituted carboplatin for cisplatin in the combination in order to improve the therapeutic index. From March 1992 to March 1994, 55 untreated patients with undifferentiated unresectable or metastatic adenocarcinoma or large-cell carcinoma of the lung were recruited. The treatment consisted of a course of carboplatin (300 mg/m2) and vinorelbine (25 mg/m2) repeated every 4 weeks. The only grade 3 toxicity observed was 16 cases of grade 3 vomiting and 2 cases of grade 3 stomatitis. RESULTS: The positive response rate was 40% (partial response, 22 patients). In conclusion, the vinorelbine-carboplatin combination may be regarded as an active, safe regimen for the palliative treatment of advanced adenocarcinoma or large-cell carcinoma of the lung.

[Abdominal metastasis of cardias adenocarcinoma]. / Studio della diffusione neoplastica addominale nell'adenocarcinoma del cardias.

BACKGROUND: The aim of the present study was to evaluate the incidence of abdominal lymph node involvement of adenocarcinoma of the gastric cardia in relationship with the site and depth of tumor invasion. METHODS: From July 1988 to April 1998, 79 patients with adenocarcinoma of the gastric cardia underwent surgical curative resection and D2 lymphadenectomy at the 1st Department of General Surgery of Verona University. Among these 79 patients, 16 had an adenocarcinoma of the distal esophagus (type I), 26 patients had an adenocarcinoma of the anatomic cardia (type II) and 37 had a subcardial adenocarcinoma (type III). The frequency of lymph node involvement in each of the lymph nodes as classified by the JRSGC were analyzed. RESULTS: In type I carcinoma positive lymph nodes occurred in 20% of pT1, 33% of pT2 and 100% of pT3. Positive nodes along the lower half of the stomach were never found. In type II carcinoma positive lymph nodes occurred in 57% of pT1, 86% of pT2 and 83% of pT3. Metastasis along the greater curvature in 18% of advanced cancers were found. In type III carcinoma positive lymph nodes occurred in 83% of pT2, 94% of pT3 and in 100% of pT4. Nodes along greater curvature were involved in 21% of advanced cases and also infrapyloric lymph nodes involved in 13% of cases. The type II and III advanced tumors had involved paraortic lymph node in 33% of cases. CONCLUSIONS: These results suggest that for tumors of the cardia an extended lymphadenectomy is necessary to ensure the removal of all metastatic nodes.

[Neoadjuvant chemoradiotherapy in esophageal cancer]. / Chemio-radioterapia neoadiuvante nel cancro dell'esofago.

From June 1987 to December 1993 in our Institute we treated with neoadjuvant chemo-radiotherapy 94 patients with esophageal squamous carcinoma. The neoadjuvant protocol consisted in 3000 cGy and two cycles of chemotherapy (5-FU, 1000 mg/m2, 100 mg/m2 DDP). At the end of this treatment patients underwent surgery. Operability rate was 76.6%, post-operative morbidity was not affected by the neoadjuvant treatment and post-operative mortality rate was 9.5%. Histopathology showed in 15 cases no residual disease (T0) and in 12 patients minimal residual of disease, with isolated neoplastic microfoci in the esophageal wall. The longest survival was of seventy months with medium follow-up of 16.8 months. Overall actuarial survival (Kaplan-Meier test) at one, two, three years were 54%, 34%, and 23% respectively. Our experience showed a better survival of the patients treated with surgery alone, a better operability and resectability rates. However, it is mandatory to wait for the results of perspective randomized studies to evaluate the real advantages of this treatment.

[A comparison between manual and mechanical anastomoses in digestive organ surgery]. / Confronto tra anastomosi manuali e meccaniche in chirurgia digestiva.

The authors review the literature from 1980 to 1990 about some kinds of digestive anastomosis: esophagogastric and esophagocolic anastomosis at neck, esophagogastric intrathoracic anastomosis, esophagojejunal anastomosis, colorectal anastomosis. They compare the results of manual versus mechanical procedure in the light of recent personal clinical experience.

[Thromboembolectomy by Fogarty's catheter (experience in 416 interventions)]. / La tromboembolectomia mediante catetere di Fogarty (esperienza su 416 interventi).

Thrombo-embolectomy by means of a Fogarty balloon catheter became part of routine surgical practice more than twenty years ago with a standardized method and technique. The authors report on a surgical population spread over ten years' activity (1975-1985) in the Institute of Surgical Pathology of the University of Verona with records of 416 emergency operations to remove thrombo-embolisms. Owing to its lack of operative mortality and the minimal trauma it causes, the technique is now strongly indicated and widely used. On the basis of their experience, however, the authors stress the need to adhere to certain basic principles: early recognition of the disease (within 12 hours); early anticoagulation of patients; immediate surgery. It is only by adopting such a policy that better results may be obtained in future and the number of amputations reduced.

[Current state of sympathectomy in peripheral reconstructive surgery]. / Attualità della simpaticectomia nella chirurgia ricostruttiva periferica.

The Authors present the results got regarding operations of sympathectomy together with operations of distal by-pass at the Institute of Surgical Pathology of the University of Verona from 1979 to 1983. Among the 106 cases, in 58 (55%) sympathectomy was performed with a aorto-bifemoral or iliac-femoral by-pass at the same time, in 48 (45%) pas performed with more distal by-pass. At follow-up in the 72% of the cases a clinical improvement as been noticed, in the 14.5% of the cases a steady result as been found, and in the 12.6% of the cases an aggravation of the situation. Furthermore the clinical stage of the disease (according to Fountain) as been compared with the operation. The Authors concluded that the sympathectomy carried out together with other vascular surgical operations is still a good procedure if the patients are within 70 years of age, no diabetics and pith a sufficient perfusion pressure of the ankle. Moreover, paradoxically, the sympathectomy is much more useful on stage II or III than on stage IV.

[The treatment of recurrences in the surgery of reflux diseases]. / Trattamento delle recidive della chirurgia nella malattia da reflusso (MRGE).

The authors, basing on their own experience and after a wide review of the literature, analyse the incidence and the etiopathogenesis of the relapses after surgical operations for gastro-esophageal reflux. Furthermore they point out the actual trends in diagnosis and medical therapy and the indications for surgical therapy.

[Leiomyoma of the nipple (a case report and review of the literature)]. / Il leiomioma del capezzolo (presentazione di un caso e revisione della letteratura).

The leiomyoma of the nipple is a very rare affection. No more than 20 cases are reported in the literature of the last 50 years. This neoplasm presents a difficult differential diagnosis with the remaining phlogistic and neoplastic breast diseases. We report a personal case with a review of the literature.

[Conservative treatment of stenosis of the pylorus. A proposal of a technic and results]. / Trattamento conservativo delle stenosi del piloro. Proposte di technica e risultati.

The authors reported 6 cases of pyloric stenosis treated endoscopically by a new technic. Results have been good in all cases.

[Prognostic value of histologic classifications of advanced stomach cancer: comparative study of Lauren's and Goseki's classifications]. / Valore prognostico delle classificazioni istologiche del cancro dello stomaco avanzato: studio comparativo fra classificazione di Lauren e di Goseki.

Controversy exists about the prognostic value of the histological classifications of gastric cancer commonly used. Recently Goseki proposed a new classifying system based on intracellular mucus production and the degree of tubular differentiation. The aim of this study was to compare Lauren and Goseki classifications with particular emphasis on their prognostic significance. Eighty-nine patients, who underwent potentially curative resections (RO) and radical lymphadenectomy for advanced gastric cancer from September 1988 to April 1996 were analysed. Cox regression model was used to evaluate the prognostic significance of Goseki classification, Lauren classification, age, sex, type of lymphadenectomy, depth of tumour invasion (T), node metastases (N) and number of metastatic nodes. A statistically significant correlation between the different Goseki grades and histology according to Lauren was found (p < 0.001). By multivariate analysis the only parameters predictive of long term outcome were depth of tumour invasion, nodal status and histology according to the Lauren classification. Also after excluding the Lauren classification from the analysis, the Goseki histological grading system did not affect survival independently. This study on advanced gastric cancer patients identified depth of invasion, lymph node metastases and Lauren classification as significant independent pathological variables influencing survival. The classification proposed by Goseki did not add anything further to the prognostic informations provided by TNM staging and Lauren classification.

[Emergencies in carcinoma of the esophagus]. / Le urgenze nel carcinoma dell'esofago.

The authors reviewed their experience in the emergency treatment of complications of esophageal cancer. They have treated 5 cases of acute obstruction, bleeding (4 cases), perforations or rupture (5 cases), feeding and neoplastic obstruction of esophageal endoprostheses (30 cases), dislocations and migrations of endoprostheses (15 cases), damage of endoprostheses (1 case) and, finally, acute complications after laser treatment.