Fabrizio Romano

Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections

PurposeSurgical site infections (SSIs) are the most common infections in colorectal surgery. Although some studies suggest that rectal surgery differs from colon surgery for SSI incidence and risk factors, the National Nosocomial Infection Surveillance system categorizes all colorectal surgeries into only one group. The aim of this study was to determine incidence, characteristics, and risk factors of SSIs according to the subclassification of colorectal surgery into right colon surgery (RCS), left colon surgery (LCS), and rectum surgery (RS).MethodsFrom November 2005 to July 2009, all patients requiring colorectal resectioning were enrolled into our program. The outcome of interest was an SSI diagnosis. Univariate and multivariate analyses were performed to determine SSI predictors in each group.ResultsTwo hundred seventy-seven consecutive colorectal resections were analyzed. SSI rates were 8% in RCS, 18.4% in LCS, and 17.6% in RS. LCS and RS showed significantly higher SSI incidences (pu2009=u20090.022) and greater rates of organ/space infections compared to RCS (pu2009=u20090.029). Predictors of SSI were steroid use among RCS, age greater than 70xa0years, multiple comorbidities, steroid use, non-neoplastic colonic disease, urgent operation, ostomy creation, postoperative intensive care among LCS, preoperative chemoradiation, heart disease, and prolonged operation among RS patients. On multivariate analysis, the coupled LCS and RS groups showed an increased risk for SSI compared to RCS (OR, 2.57).ConclusionsSSI incidences, characteristics, and risk factors seem to be different among RCS, LCS, and RS. A tailored SSI surveillance program should be applied for each of the three groups, leading to a more competent SSI recognition and reduction of SSI incidence and related costs.

Combined hepatocellular‐cholangiocarcinoma: A population‐level analysis of an uncommon primary liver tumor

Combined hepatocellular‐cholangiocarcinoma (cHCC‐CC) is a rare primary liver cancer. Our aims were to analyze the demographic, clinical, and pathological characteristics of cHCC‐CC at a population level and to investigate the effects of these features as well as different management strategies on the prognosis. The Surveillance, Epidemiology, and End Results (SEER) database was analyzed for 1988‐2009. Data analyses were performed with chi‐square tests, analyses of variance, Kaplan‐Meier curves, and Cox proportional hazards regression. Four hundred sixty‐five patients with cHCC‐CC, 52,825 patients with hepatocellular carcinoma (HCC), and 7181 patients with cholangiocarcinoma (CC) were identified. cHCC‐CC was more common in patients who were white, male, and older than 65 years. Treatment was more frequently nonsurgical/interventional. Patients with cHCC‐CC, HCC, and CC had 5‐year overall survival (OS) and disease‐specific survival rates of 10.5%, 11.7%, and 5.7% (Pu2009<u20090.001) and 17.8%, 21.0%, and 11.9% (Pu2009<u20090.001), respectively. For cHCC‐CC patients, an increasing invasiveness of the therapeutic approach was significantly associated with prolonged survival (Pu2009<u20090.001). In a multivariate model, black race, a distant SEER stage, and a tumor size of 5.0 to 10.0 cm were independently associated with lower survival for cHCC‐CC patients; a year of diagnosis after 1995 and surgical treatment with minor hepatectomy, major hepatectomy (MJH), or liver transplantation (LT) were independently associated with better survival for cHCC‐CC patients. Patients diagnosed with cHCC‐CC, HCC, and CC and treated with LT had 5‐year OS rates of 41.1%, 67.0%, and 29.0%, respectively (Pu2009<u20090.001). In conclusion, cHCC‐CC patients appear to have intermediate demographic, clinical, and survival characteristics in comparison with HCC and CC patients. cHCC‐CC patients undergoing LT showed inferior survival in comparison with HCC patients, and the role and indications for LT in cHCC‐CC have yet to be defined. At this time, MJH may be considered the best therapeutic approach for such patients. Liver Transpl 20:952–959, 2014.

Surgical treatment of liver metastases of gastric cancer: state of the art

BackgroundThe prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.

Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients

PurposeEarly laparoscopic cholecystectomy (ELC) is the treatment of choice for acute cholecystitis (AC), but the optimal surgical timing is controversial. The aim of this study was to retrospectively verify the outcome of patients with AC according to different timing of cholecystectomy.MethodsPatients undergoing cholecystectomy for AC from 2006 to 2012 were stratified into two groups: initial admission cholecystectomy (IAC) and delayed cholecystectomy (DC, after at least 4xa0weeks). Among IAC, a subgroup undergoing immediate cholecystectomy (IC, within 72xa0h of symptom onset) was further analyzed.ResultsThree-hundred and sixteen consecutive patients were studied. IAC group included 262 patients (82.9xa0%) and DC group included 54 patients (17.1xa0%). The two groups were similar in conversion rate, operation length, and overall complication rate. The total length of hospitalization was longer in DC patients (pu2009=u20090.005). Among DC patients, 25.9xa0% required re-hospitalization while waiting an elective procedure. In the group undergoing IC (66 patients), conversion rate, length of operation, and postoperative morbidity were similar to that of the IAC group. Length of stay was shorter in IC group (pu2009<u20090.001). Multivariate analysis identified moderate–severe AC grading and ASA scoreu2009≥u20093 as predictors of postoperative complications.ConclusionsThe timing of cholecystectomy for AC does not seem to affect conversion rate and postoperative morbidity. Therefore the 72-h period should not be considered a strict limit to perform LC, provided that the operation is carried out during the initial hospital admission.

Interleukin-2 immunotherapy action on innate immunity cells in peripheral blood and tumoral tissue of pancreatic adenocarcinoma patients.

Background and aimsInnate immunity cells play a crucial role in host anticancer defense: cancer patients with high levels of natural killer (NK) cells and eosinophils have a better prognosis. Recombinant interleukin-2 (rIL-2) immunotherapy stimulates innate immunity cells. This study aims to evaluate the toxicity of pre- and postoperative rIL-2 treatment and the effects on innate immunity both in peripheral blood and in cancer tissue of patients with resectable pancreatic adenocarcinoma.Materials and methodsSeventeen patients received high dose rIL-2 preoperative subcutaneous administration and two low dose postoperative cycles. We evaluated NK cell and eosinophil count in blood and in pancreatic surgical specimens.ResultsToxicity was moderate. In the early postoperative period, blood NK cells and eosinophils significantly increased compared to basal values (pu2009<u20090.02). Histopathological analysis did not find significant intratumoral infiltration of NK cells nor of eosinophils.ConclusionsPreoperative high dose rIL-2 administration is able to counteract surgery-induced deficiency of NK cells and eosinophils in peripheral blood in the early postoperative period, although it cannot overcome local mechanisms of immune tumor escape in cancer tissue. The amplification of innate immunity, induced by immunotherapy, may improve the control of metastatic cells spreading in the perioperative period.

Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter “Blood Loss” has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.

Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review

BackgroundHepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases.MethodsWe identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4xa0% of these subjects were resected.ResultsNo prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8xa0%), genito-urinary (21.8xa0%), and gastrointestinal tract (19.8xa0%). The median 5- and 10-year overall survival were 32.3xa0% (range 19–42xa0%) and 24xa0% (indicated only in two studies, range 23–25xa0%), respectively, with 71xa0% of R0 resections.ConclusionsThere is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.

Low-dose Interleukin-2 Administered Pre-operatively to Patients with Gastric Cancer Activates Peripheral and Peritumoral Lymphocytes But Does Not Affect Prognosis

BackgroundThere is evidence that cancer is immunogenic under certain situations. IL-2 is described to stimulate an effective antitumor immune response in vitro and in vivo. The ability of cancer patients to undergo surgical resection is still the most important prognostic factor for many solid tumors, including gastric adenocarcinoma. The host immune system may be further compromised by surgical procedures leading to a generalized state of immunodepression in the post-operative period. The aim of this randomized case–control study is to evaluate the effects of pre-operative low-dose IL-2 treatment on patients with gastric adenocarcinoma who undergo surgery.MethodsSixty-eight patients with gastric adenocarcinoma were enrolled in the study and randomized in two groups: 36 patients were pre-treated with IL-2 and 32 underwent surgery without any treatment. Total peripheral WBC, neutrophils, CD3+ T, CD4+ T, CD8+ T and NK cells were obtained before and after surgery, at different times. Peritumoral infiltration was analyzed on all surgical specimens. Overall survival and relapse-free survival were studied with a median follow-up of 51 months.ResultsLow-dose IL-2 treatment resulted in an increase peritumoral lymphocytic and eosinophilic infiltrations and in a minor decrease in CD3+ T and CD4+ T cells after surgery (Pxa0<xa00.05). A stepwise multivariate analysis revealed that overall survival and relapse-free survival were affected only by stage of tumor and age of patients.ConclusionsAccording to our data low-doses of IL-2 administered pre-operatively to patients with gastric cancer activate peripheral and peri-tumoral lymphocytes but did not affect prognosis.

Challenging diagnosis of ileal gastrointestinal stromal tumor presenting with obscure digestive bleeding.

We report a case of a patient observed in emergency condition for recurrent episodes of massive obscure gastrointestinal bleeding that required surgical control. At laparotomy we found an ileal mass with the characteristics of a gastrointestinal stromal tumor (GIST) at histopathological analysis. GISTs should always be considered as a possible cause of obscure gastrointestinal bleeding, although they are often difficult to diagnose preoperatively. Laparotomy is sometimes the only way to obtain a diagnosis. Starting from this case, we reviewed the literature about GISTs, focusing our attention on their diagnosis and the possible surgical and nonsurgical therapies.

Prolonged survival of a patient affected by pancreatic adenocarcinoma with massive lymphocyte and dendritic cell infiltration after interleukin-2 immunotherapy. Report of a case.

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanI2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, R1, tumor grade G3).