Antonio Santoriello

Inguinal hernia repair in patients with coagulation problems: Prevention of postoperative bleeding with human fibrin glue

BACKGROUND Our purpose was to establish the efficacy of human fibrin glue (HFG) in preventing coagulative complications after inguinal hernia repair in patients with coagulation disorders. METHODS A randomized controlled trial of 50 patients with coagulation disorders undergoing hernia repair was performed. Patients had concurrent coagulopathies as a consequence of liver disease or long-term treatment with anticoagulants. Coagulopathies were defined according to the following criteria: prothrombin time < 10.5 seconds, activated partial thromboplastin time < 21 seconds, and fibrinogen < 230 mg/dL. Patients were randomized in a 1:1 ratio with (group A) or without (control group B) use of HFG. RESULTS Postoperative hemorrhagic complications were significantly reduced in group A (4%) compared with group B (24%). CONCLUSION This study shows that HFG is effective in preventing local hemorrhagic complications after herniorrhaphy in patients with concurrent coagulation disorders. This implies that the use of HFG reduces the costs of prolonged hospitalization related to such complications.

Electrochemotherapy of cutaneous metastastes from breast cancer in elderly patients: a preliminary report.

BackgroundThe management of cutaneous metastases often represents a challenge because they may be widespread and may recur after radiotherapy or chemotherapy; breast cancer accounts for 51% of the total cases of cutaneous metastases. When surgical excision of chest wall recurrences is not possible and other local treatments such as radiotherapy or radiotherapy with hyperthermia fail, topical chemotherapy and electrochemotherapy (ECT) might be taken into account.ECT is a new local treatment of solid tumors which can be defined as the local potentiation, by means of permeabilizing electric pulses, of the antitumor activity of a non permeating anticancer drug with high intrinsic cytotoxicity.MethodsThis prospective observational study took place throughout March 2010 to October 2011. Twelve consecutive elderly patients (1 man and 11 women, median age of 76 years) with regional or distant skin or subcutaneous metastases from breast cancer, with or without visceral disease, were included in the study. Patient enrollment was carried out according to the ESOPE criteria. Bleomycin administration was followed by the application of brief electric pulses to each tumor nodule within 8 min after intravenous infusion of the drug. Electric currents were delivered by means of a 2–3 cm long needle electrode according to lesion size. All treatments were performed using the CliniporatorTM device.ResultsWe observed Complete Response(CR) in 75.3% (107 metastases), Partial Response(PR) in 17% (24 metastases), no change in 7.7% (11 metastases) . No serious ECT-related adverse events were reported; adverse events consisted of pain in the treated area one to two days after treatment (1 patient, 8.3%) and ulceration of treated area (1 patient, 8.3%).ConclusionECT could be suggested as a primary local therapy in patients not suitable for surgical removal of the primary tumor, and clinicians should not hesitate to use it even in the elderly.

Sutureless fixation with fibrin glue of lightweight mesh in open inguinal hernia repair: effect on postoperative pain: a double-blind, randomized trial versus standard heavyweight mesh.

BACKGROUND Open inguinal hernia repair is associated with a low incidence of complications that can be influenced by the type of mesh and its method of fixation. Our aim was to investigate the frequency and severity of postoperative pain and other complications when lightweight, large-pore meshes, compared with heavyweight, small-pore meshes, are fixed with human fibrin glue (HFG) during open inguinal hernia repair. METHODS A cohort of 80 patients undergoing open inguinal repair were enrolled. Forty patients received a lightweight and large porous mesh and 40 a standard heavyweight mesh with small pores. In all patients, HFG was used for mesh fixation. RESULTS Patients who received lightweight, large-pore mesh reported less pain than those in the control group both postoperatively (2.8 ± 1.1 vs. 4.9 ± 1.1; P = .0003) and at 1-month follow-up (1.7 ± 1.0 vs. 3.1 ± 1.0; P = .0038), and took fewer analgesics. There was no difference in days off work/activity. No differences were observed concerning postoperative complications. After 6 months there was no difference in groin pain between groups. CONCLUSION Patients who underwent open inguinal hernia repair with lightweight, large-pore mesh fixed with HFG experienced less pain throughout the first month after operation compared with those receiving standard mesh.

Preventive NPWT over closed incisions in general surgery: Does age matter?

Surgical site events (SSE), including surgical wound complications and surgical site infections, are a major concern in patients undergoing general surgery operations. These increase the costs of care, and can lead to prolonged hospital stay and need for further treatments, ultimately resulting in poor quality of life. Negative pressure wound therapy (NPWT) has been recently reported as a preventive strategy to avoid SSE, but little is known on the topic, and particularly in geriatric population. Our primary aim was to assess the efficacy of NPWT by means of a pocket device (PICO, Smith & Nephew, London, UK) in preventing SSE compared with conventional dressings in patients undergoing surgery with primary wound closure for breast and for colorectal diseases in our Unit. Our secondary aims were to assess the efficacy and safety of PICO in elderly patients, and to seek for differences between breast and abdominal results. All consecutive patients undergoing breast and colorectal surgery in our Unit between September 2012 and May 2014 were prospectively enrolled in this open label controlled study. Breast patients receiving NPWT were assigned to group B1, those receiving conventional dressings were assigned to group B2. Colorectal patients were assigned to group C1 (NPWT) and C2 (conventional dressings) in similar fashion. Each group included 25 patients, and at least 10 (40%) patients aged over 65 years to allow sub-analyses. NPWT significantly reduced SSE in both breast and colorectal patients compared with controls. No significant differences were observed according to age. Similar benefits were observed in breast and colorectal patients. Our results suggest that PICO is an effective tool to prevent SSE in patients undergoing general surgery, irrespective of age. Its use is recommended in frail, elderly patients at risk of SSE.

Stepwise approach and surgery for gallbladder adenomyomatosis: a mini-review

BACKGROUND Gallbladder adenomyomatosis (GBA) is a hyperplastic disease affecting the wall of the gallbladder, with some typical features. It has historically been considered a benign condition, nevertheless recent reports highlighted a potential role of GBA in predisposing to malignancies of the gallbladder. DATA SOURCES We reviewed the literature concerning GBA from its identification until July 2012. Owing to the relative rarity of the disease, studies often are case reports or case series. Thus we herein report a summary of the key-points concerning diagnosis and treatment of GBA, easily applicable in everyday practice, rather than a systematic review. Also, results are integrated with our recent experience. RESULTS In our experience, we observed a trend toward an increase of GBA during the last years, probably due to enhanced ultrasonographic technical advancements and physicians expertise. GBA has distinctive imaging features. Several recent reports highlight the potential risk of cancer associated with GBA; however the disease is still classified as a benign condition. Although its correlation with malignancy has not been demonstrated, it is prudent to recommend cholecystectomy in some cases. However, in selected asymptomatic patients, a wait-and-see policy is a viable alternative. We propose an algorithm, based on GBA pathological pattern (diffuse, segmental, localized or fundal), suitable for decision-making. CONCLUSIONS In symptomatic patients and if the diagnosis is doubtful, cholecystectomy is mandatory. Postponing surgery is an option to be offered to asymptomatic patients with low-risk GBA pattern who adhere to scheduled follow-ups.

Incidence of breast cancer in Italy: mastectomies and quadrantectomies performed between 2000 and 2005.

ObjectivesWe aimed to determine the incidence of womens breast cancer in Italy without using statistical approximations.MethodsWe analyzed the national hospitalizations database at the Ministry of Health to calculate the number of major surgeries in Italian women (mastectomies and quadrantectomies) due to breast cancer between 2000 and 2005, overall and by age groups (<44, 45–64, 65–74 and ≥ 75 years old).ResultsOver the six years examined, an overall number of 100,745 mastectomies and 168,147 quadrantectomies were performed. A total of 41,608 major surgeries due to breast cancer were performed in the year 2000 and this number rose to 47,200 in 2005, with a 13.4% increase over six years.Conclusionby analyzing the hospitalizations database concerning major breast surgery, incidence of breast cancer in Italy was found to be 26.5% higher than the official estimations which have been computed using statistical models (namely 47,200 vs. 37,300 cases in year 2005).

The burden of breast cancer in Italy: Mastectomies and quadrantectomies performed between 2001 and 2008 based on nationwide hospital discharge records

BackgroundWhere population coverage is limited, the exclusive use of Cancer Registries might limit ascertainment of incident cancer cases. We explored the potentials of Nationwide hospital discharge records (NHDRs) to capture incident breast cancer cases in Italy.MethodsWe analyzed NHDRs for mastectomies and quadrantectomies performed between 2001 and 2008. The average annual percentage change (AAPC) and related 95% Confidence Interval (CI) in the actual number of mastectomies and quadrantectomies performed during the study period were computed for the full sample and for subgroups defined by age, surgical procedure, macro-area and singular Region. Re-admissions of the same patients were separately presented.ResultsThe overall number of mastectomies decreased, with an AAPC of −2.1% (−2.3 -1.8). This result was largely driven by the values observed for women in the 45 to 64 and 65 to 74 age subgroups (−3.0%, -3.4 -3.6 and −3.3%, -3.8 -2.8, respectively). We observed no significant reduction in mastectomies for women in the remaining age groups. Quadrantectomies showed an overall +4.7 AAPC (95%CI:4.5–4.9), with no substantial differences by age. Analyses by geographical area showed a remarkable decrease in mastectomies, with inter-regional discrepancies possibly depending upon variability in mammography screening coverage and adherence. Quadrantectomies significantly increased, with Southern Regions presenting the highest average rates. Data on repeat admissions within a year revealed a total number of 46,610 major breast surgeries between 2001 and 2008, with an overall +3.2% AAPC (95%CI:2.8-3.6).ConclusionsIn Italy, NHDRs might represent a valuable supplemental data source to integrate Cancer Registries in cancer surveillance.

Granulomatous lobular mastitis: another manifestation of systemic lupus erythematosus?

Granulomatous lobular mastitis (GLM) is a benign disease of the breast generally affecting women of child-bearing age. Diagnosis is based on findings of noncaseating granulomatous inflammation at histologic evaluation of biopsy. GLM has been reported in association with infectious diseases (tuberculosis, bacterial, fungal, or parasitic infections), vasculitis (Wegener’s granulomatosis, sarcoidosis, giant cell arteritis, polyarteritis nodosa), foreign body reaction (e.g., breast implants), and oral contraceptive usage. When an apparent etiology cannot be found, GLM is defined as idiopathic. Pathogenesis is unknown, although an abnormal immune response has been hypothesized to underlie the development of this condition. Accordingly, we report here a case of GLM associated with a serological profile indicative of combined systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), clinically mimicking multifocal breast cancer (Fig. 1). A 65-year-old woman was referred to our Institution because of multiple nodular lesions in both breasts resembling multifocal cancer. Her past medical history was remarkable for a non-ST-elevation myocardial infarction (NSTEMI) occurred at age 40. Relevant laboratory tests included positivity for both ANA (1:1280, homogeneous + nucleolar pattern) and anti-dsDNA (indirect immunofluorescence on Crithidia luciliae), prolonged aPTT (67.7′′), detection of both anticardiolipin IgG (271 GPL U/mL; n.v.: <10) and anti-b2-glycoprotein I IgG (177 UA/mL; n.v.: <10), and consumed complement C4 (8 mg/dL; n.v.: 12– 52). Both patients’ breasts were subjected to excisional biopsy. However, contrary to the initial diagnostic suspicion, the patient was diagnosed as having granulomatous lobular mastitis (Fig. 2). The patient denied clinical complaints attributable to SLE/APS. No pregnancy morbidity/losses were reported during childbearing age. Physical examination was normal, apart from breast involvement. Cultures of breast tissue for bacterial, mycobacterial, and fungal pathogens were negative. Intradermal PPD was negative at a 72-hour

Interplay between membrane lipid peroxidation, transglutaminase activity, and cyclooxygenase 2 expression in the tissue adjoining to breast cancer.

Breast cancer, a leading cause of cancer related deaths worldwide, is one of the most common neoplasms in women. The increased generation of reactive oxygen species (ROS) in breast lesion is critically involved in the mutagenic processes that drive to breast carcinoma initiation and progression. To date, the molecular events occurring in the tissue adjoin the cancer lesion have not been elucidated. Here, we investigated the role of excess ROS generation during human breast carcinogenesis by evaluating oxidative stress biomarkers, tissue transglutaminase (t‐TGase) activity, and expression levels of ubiquitin and cyclooxygenase‐2 (COX‐2) in the normal tissue adjoin to fibroadenoma (nFA), atypical ductal hyperplasia (nADH), and invasive ductal carcinoma (nIDC) from 45 breast cancer patients. We found that lipid peroxidation and nitric oxide production significantly increased in nIDC respect to nFA and nADH (P < 0.005) whereas the 4‐hydroxy‐2‐nonenal (HNE) protein‐adducts increased only in nADH (P < 0.005). The increased lipid damage observed in nIDC correlates with estrogen receptor exposure in IDC (R2 = 0.89). Moreover, nIDC and invasive ductal carcinoma (IDC) showed a 10‐fold higher t‐TGase activity compared to nFA and nADH. Contrary, COX‐2 expression levels significantly decreased nIDC and IDC respect to the nFA and nADH (P < 0.001). The analysis of the free ubiquitin expression revealed equal levels in nADH and nIDC samples whereas high molecular weight‐ubiquitin conjugate increased about fivefold only in nIDC (P < 0.01 vs. nADH). These novel findings reveal an interplay between membrane lipid peroxidation, t‐TGase activity, and COX‐2 expression levels in the tissue adjoining to neoplastic lesion during breast cancer progression. J. Cell. Physiol. 227: 1577–1582, 2012.

Angiosarcoma of the breast: a new therapeutic approach?

Highlights • We report the case of a 76-year-old woman who developed an exuberant and aggressive post radiation angiosarcoma of the breast and discuss different aspects of therapy for this disease.• The lesions into the chest wall, and multiple abdominal skin nodules were treated with local Electrochemotherapy (ECT) with intravenous bleomicin.• Treatment with ECT in addition to systemic chemotherapy achieves a complete response in all the lesions and improving patient body image perception.