Franco Uggeri

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.

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.

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).

Chronic gastric obstruction due to giant trichobezoar in an adult with Rapunzel syndrome

A 46-year-old woman was admitted to psychiatric ward accomanied by parents for delirium during acute phase of psychosis. uring following days a voluminous non-painful mass in the left pper quadrant of abdomen was noted. Detailed studies of medcal history reveal a story of nausea and vomiting during last onths and weight loss. A contrast enhanced CT scan was perormed and the images were suggestive for impressive gastric ilatation sustained by a giant bezoar (Fig. 1). The diagnosis was hen confirmed during endoscopic procedure during which was mpossible to remove the bezoar due to impossibility to fragment t in smaller pieces. A laparotomy was planned, the trichobezoar as removed through a 10 cm longitudinal gastrotomy on the nterior gastric wall (Fig. 2). The gastrotomy was repaired with linar mechanical stapler and a reinforcement with manual suture.

Effective application of Ligasure in laparoscopic splenectomy for splenic abscess in an old woman – case report

Materials and methods We present the case of an 84-year-old woman, affected by essential thrombocythemia, monoclonal gammopathy and senile dementia, who was admitted in our Hospital for abdominal pain and high white blood cells levels. An abdominal CT scan showed splenic infarctual abscess and a broad-spectrum antibiotic therapy was arranged. Because of the unfavourable clinical evolution, a laparoscopic splenectomy was indicated.

Surgical management of hepatocellular carcinoma within and beyond BCLC indications in a middle volume center

AIM OF THE STUDYnCurrent criteria for hepatic resection in patients with hepatocellular carcinoma (HCC) according to Barcellona Clinic Liver Cancer (BCLC) classification is debated. Actually, patients with multinodular or large HCC>5cm are excluded from surgical treatment following the algorithm, but several studies from referral centers showed that such patients may benefit from surgical resection in the clinical practice. The aim of this study was to compare short- and long-term outcomes after liver resection for HCC in stage 0/A or B in a middle volume center.nnnPATIENTS AND METHODSnPatients were grouped according to BCLC classification. Postoperative mortality, morbidity, overall and disease-free survival, univariate analysis of prognostic factors on survival was analyzed.nnnRESULTSnAmong 66 surgical procedures in 64 patients included in the study, 41 were BCLC stage 0/A (62.1%) and 25 BCLC stage B (37.9%). The overall 30- and the 90-days mortality rates were 1.5% and 3%. Patients in BCLC stage B had higher transfusion rate (P=0.04) but similar morbidity and mortality compared to patients in BCLC stage 0/A. After a median follow-up of 35 months (range: 14-147), the overall survival at 1, 3 and 5 years resulted 95%, 61.1%, 46.2% for stage 0-A and 83.3%, 50%, 41.2% for stage B (P=0.73). Univariate analysis identified poorly differentiated tumors (P=0.02) and positive margin (P=0.02) as negative prognostic factors on survival.nnnCONCLUSIONSnSurgical treatment of HCC in BCLC stage B offers similar results than the ones in BCLC stage 0/A and consequently should not be considered contraindicated for such patients.