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There is increasing evidence that early liver transplantation (eLT), performed within standardized protocols can improve survival in severe alcoholic hepatitis (sAH). The aim of the study was to assess outcomes after eLT for sAH in four Italian LT centers and to compare them with non-responders to medical therapy excluded from eLT. Patients admitted for sAH (2013–2019), according to NIAAA criteria, were included. Patients not responding to medical therapy were placed on the waiting list for eLT after a strict selection. Histological features of explanted livers were evaluated. Posttransplant survival and alcohol relapse were evaluated. Ninety-three patients with severe AH were evaluated (65.6% male, median [IQR] age: 47 [42–56] years). Forty-five of 93 patients received corticosteroids, 52 of 93 were non-responders and among these, 20 patients were waitlisted. Sixteen patients underwent LT. Overall, 6-, 12-, and 24-month survival rates were 100% significantly higher compared with non-responders to medical therapy who were denied LT (45%, 45%, and 36%; p&nbsp

A 34-year-old patient underwent liver transplantation for progressive hepatic failure in the setting of congenital hepatic fibrosis. In past medical history, the patient had undergone splenectomy with proximal Linton’s splenorenal surgical shunt creation for symptomatic portal hypertension with hypersplenism. The patient developed an early allograft dysfunction, with radiologic evidence of a reduced portal flow associated to portal steal from the patent surgical shunt. The patient was successfully treated through endovascular placement of a 30 mm Amplatzer cardiac plug at the origin of the splenic vein.

Background: The benefits of pure laparoscopic and robot-assisted liver resections (LLR and RALR) are known in comparison to open surgery. The aim of the present retrospective comparative study is to investigate the role of RALR and LLR according to different levels of difficulty. Methods: The institutional databases of six high-volume hepatobiliary centers were retrospectively reviewed. The study population was divided in two groups: LLR and RALR. The procedures were stratified for difficulty levels accordingly to three classifications. A propensity score matching was implemented to mitigate selection bias. Short-term outcomes were the object of comparison. Results: Nine hundred and thirty-six LLR and 403 RALR were collected. RALR exhibited fewer cases of intraoperative blood loss, lower transfusion and conversion rates (especially for oncological radicality) than LLR in the setting of highly difficult operations, whereas LLR had lower postoperative morbidity and fewer low-grade complications. For intermediate and low-difficulty resections, the intraoperative advantages of RALR gradually decreased to nonsignificant results and LLR remained associated with lower postoperative morbidity. Conclusion: Robot-assisted liver resections do not show operative nor clinically significant benefits over LLR for low- and intermediate-difficulty resections. By reducing conversion rates, RALR can favour the operative feasibility of difficult resections possibly extending the indications of minimally invasive approaches for liver resection.

Mechanical circulatory support (MCS) refers to a range of rescue devices to assist circulation for the treatment of heart failure, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and ventricular assist devices (VADs). This review aims at evaluating the transplant outcome of the livers procured from brain-dead donors on MCS, who are currently considered as having extended criteria. We identified 22 records (17 on VA-ECMO and 5 on VADs), most of which (68.2%) were case reports. We performed a meta-analysis only when the outcome was reported homogeneously among studies; otherwise, we illustrated the results with narrative synthesis. A total of 156 liver transplants (LTs) have been reported, where VA-ECMO was initiated in the donor with resuscitative intent or as a bridge to donation. Early graft survival approached 100% in most studies. The pooled rate of primary nonfunction was 1% (95% CI: 0-3%). Only three successful LTs from VAD donors have been reported. Particular attention should be paid to cardiological history, biochemical tests, and imaging, as well as MCS parameters, to determine graft eligibility for transplantation. Although further analysis is needed in this field, the results of this review advocate a more systematic consideration of brain-dead patients on MCS as potential liver donors.

Purposes: We sought to investigate the accuracy of abdominal CT scanning for anastomotic leakage and the effect of false-negative scans on the delay in therapeutic intervention and clinical outcome. Method: Data from a prospectively bi-institutionally maintained database of all patients who underwent elective colorectal surgery with primary anastomosis for malignant or benign disease between 2010 and 2017 were reviewed. Patients with confirmed anastomotic dehiscence at reintervention who underwent a postoperative CT scan for suspected leakage were identified and radiological reports were retrieved. Results: Seventy-six patients with anastomotic dehiscence were included in the study. American Society of Anesthesiologists score, sex, type of surgical procedure, malignancy, and type of anastomosis do not correlate with postoperative false-negative CT imaging. Postoperative false-negative CT scan, however, led to delayed reintervention (3 vs. 6h, p = 0.023) and increased mortality (five deaths vs. no deaths, p = 0.043). Free abdominal air (p = 0.001) and extraluminal contrast extravasation (p = 0.001) were found to be predictive of accuracy in anastomotic leakage diagnosis. Conclusion: The suboptimal specificity of a postoperative CT scan in suspected anastomotic leakage after colorectal surgery can delay reintervention and increase mortality.

Introduction No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. Material and methods A prospective analysis of adult patients enrolled in the IROA. Results Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogota-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. Conclusion Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Background Laparoscopic cholecystectomy (LC) to treat mild biliary acute pancreatitis (MBAP) during index admission is recommended. However, the optimal surgical timing is controversial, considering that patients are actually often discharged from hospital and readmitted for elective cholecystectomy. Moreover, previous studies showed an uneven patients' stratification for pancreatitis severity. The aim of this study was to determine the outcome of patients homogenously categorizedfor MBAP according to the newest pancreatitis classifications, undergoing cholecystectomy with different timing. Methods We retrospectively identified all patients undergoing cholecystectomy from 2008 to 2015 for MBAP, according to the 2012 Revision of the Atlanta Classification and the Determinant-Based Classification of Acute Pancreatitis, and stratified them in two groups: index cholecystectomy (IC) and interval-delayed cholecystectomy (IDC, after at least 4 weeks). Results One hundred and three patients were analyzed. IC was performed in 40 patients (38.8%) while IDC in 63 patients (61.2%). The two groups were similar in comorbidities and pancreatitis severity at admission. There were no differences for conversion rate, operation length, total length of hospitalization and overall complication rates. However, IDC patients had a 33.3% rate of re-hospitalization for recurrent biliary-pancreatic events while waiting for the elective procedure and showed a higher rate of acute cholecystitis at histological diagnosis than IC (11.1% vs. 0%, P=0.041). Conclusions Among patients affected by MBAP, homogenously assessed following the new acute pancreatitis severity scores, the performance of cholecystectomy during the index admission is the best treatment option in order to avoid further undesired hospitalizations for recurrent biliary/pancreatic events while waiting for surgery.

Objective. The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. Methods. A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. Results. We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages. Conclusions. SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

BACKGROUND: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS: In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks. © 2012 by the authors; licensee MDPI, Basel, Switzerland.

Purpose: Surgical 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). Methods: From 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. Results: Two 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 (p∈=∈0.022) and greater rates of organ/space infections compared to RCS (p∈=∈0.029). Predictors of SSI were steroid use among RCS, age greater than 70 years, 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). Conclusions: SSI 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. © 2010 Springer-Verlag.

OBJECTIVE: To identify predictive risk factors for conversion to open splenectomy and postoperative complications in patients undergoing elective laparoscopic splenectomy. BACKGROUND: The laparoscopic approach represents the "gold standard" for splenectomy, but its use in the treatment of splenomegaly and malignant disease is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathologic. METHODS: Univariate and multivariate analyses of data from the Italian Registry of Laparoscopic Surgery of the Spleen, a multicenter database supported by 25 referral centers. Analysis of data (1993-2007) was performed on a series of patients (n = 676) undergoing elective laparoscopic splenectomy. Demographic data, the operative indications, the surgical technique applied, and any intra- and/or postoperative complications with respect to the patients were assessed. Records were analyzed retrospectively using the Student t test, the chi test, and logistic regression. RESULTS: Conversion to open splenectomy was necessary in 39 cases (5.8%). Perioperative deaths occurred in 3 cases (0.4%). There were no complications in 560 patients (82.8%), with a mean hospital stay of 5 days (range, 2-54). Overall, morbidity occurred in 116 patients (17.2%). Multivariate analysis found that the body mass index (P = 0.01) and the presence of hematologic malignancy (P < 0.001) were independent predictors for intraoperative complications and surgical conversion. Spleen longitudinal diameter (P = 0.001) and surgical conversion (P = 0.001) were independent predictors for the occurrence of postoperative complications. CONCLUSIONS: This large multicenter study provides evidence for the significance of predictive risk factors for intra- and postoperative complications in laparoscopic splenic surgery. Besides splenic dimensions, other factors like the patient's habitus and the specific underlying hematologic pathology should be recognized by the surgeon to reduce complications and initiate adequate treatment.

PURPOSE: In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy. METHODS: Forty-six patients, aged 54.6 +/- 46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27 +/- 4.8 kg/m(2). Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age. RESULTS: Mean operating time was 126.5 +/- 52 min, blood losses were 101 +/- 169 mm, conversion rate was 6.5%, morbidity was 26%, and hospitalization was 5.3 +/- 2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p = 0.007) and had more complications (p = 0.016) than those undergone operation on the right side. CONCLUSIONS: Obesity (BMI > 30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon's preference.

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.

Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery. © 2009 European Society for Clinical Nutrition and Metabolism.

Purpose: New hemostatic technologies (NT) are often employed in thyroid surgery in the effort to reduce operating time and complications. The aim of this study is to compare three different hemostatic techniques. Methods: This is a prospective randomized study. There were 150 patients, aged 56±14 years, randomized for total thyroidectomy with conventional technique (CT), Ligasure vessel sealing system (LI) or Harmonic Scalpel (HS) at the university surgical department. One hundred thirty-five patients had benign diseases; 15 had malignancies. Results: Mean postoperative hospital stay was 2.6 days. Mean operation time was 113±31 min; in HS patients, it was significantly shorter (p

Background: Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases. Materials and Methods: Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36-79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined. Results: Primary tumors were renal cell carcinoma (n = 5), lobular carcinoma of the breast (n = 3), endometrioid carcinoma of the ovary (n = 1), colonic adenocarcinoma (n = 1), jejunal leiomyosarcoma (n = 1), melanoma (n = 1), and non-small-cell lung cancer (n = 1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5-192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13-95 months). Five patients died of disease, eight are alive at the time of this report. Conclusion: A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation. © 2006 by the Société Internationale de Chirurgie.

BACKGROUND& AIMS: Perioperative nutrition with specialized enteral diets improves outcome when compared with standard formulas. A post-hoc analysis suggested preoperative administration as the most important period. Thus, we designed a study to understand prospectively whether preoperative supplementation could be as efficacious as the perioperative approach and superior to a conventional treatment (no artificial nutrition) in reducing postoperative infections and length of hospital stay. METHODS: A total of 305 patients with preoperative weight loss

Background: Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome. Methods: We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics. Results: The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7–10.6, P&nbsp

A 57-year-old woman presented with fever, vomiting and arthralgia, with a history of rheumatoid arthritis. Laboratory tests showed leucocytes, anaemia and elevation of C-reactive-protein (CRP). Blood cultures were positive for Gram negative bacteria and Streptococcus viridans. Patient underwent abdominal Computed Tomography (CT) scan revealing sigmoid acute diverticulitis with peridiverticular abscesses and thrombophlebitis within the inferior mesenteric and portal veins. She started antibiotic and anticoagulant therapy. After 20 days, a second CT revealed a thrombosis involving the superior mesenteric vein also. After 22 days of therapy the patient was discharged with the resolution of the septic status. Two months after discharge the patient underwent left hemicolectomy for a histopathologically documented diverticulitis with an uneventful postoperative course. This is a description of a rare association of septic thrombosis within the portal, inferior mesenteric and superior mesenteric veins during acute sigmoid diverticulitis with abdominal abscesses. Our therapeutic strategy was a first line medical approach and delayed surgery. © 2007 Editrice Gastroenterologica Italiana S.r.l.

Blood loss, a well-known risk factor for morbidity and mortality during liver resection, occurs during parenchymal transection, so many approaches and devices have been developed to limit bleeding. Surgical technique is an important factor in preventing intraoperative and postoperative complications. The aim of the present study was to determine whether the bipolar vessel sealing device allows a safe and careful liver transection, achieving a satisfactory hemostasis thus reducing blood loss and related complications. A total of 30 consecutive patients (18 male, 12 female with a mean age of 63 years) underwent major and minor hepatic resection in which the bipolar vessel sealing device was used without routine inflow occlusion. A crush technique followed by energy application was used to perform the parenchymal transection. No other devices were applied to achieve hemostasis. The bipolar vessel sealing device was effective in 27 cases of hepatic resection. It failed to achieve hemostasis in three patients, all of whom had a cirrhotic liver. Median blood loss was 250 ml (range: 100-1600 ml), and intraoperative blood transfusions were required in five patients (17%). Mean operative time was 200 minutes (range: 140-360 minutes). There was no clinical evidence of postoperative hemorrhage, bile leak, or intraabdorninal abscess. The postoperative complication rate was 17%. The bipolar vessel sealing device is a useful tool in standard liver resection in patients with a normal liver parenchyma, but its use should be avoided in cirrhotic livers. © 2004 by the Société Internationale de Chirurgie.

Objectives: The prognosis of patients with liver metastases of gastric cancer (LMGC) is dismal, but little is known about prognostic factors in these patients; thus justification for surgical resection is still controversial. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine which patients represent suitable candidates for surgery by assessing surgical results and clinicopathologic features. Methods: Outcomes in 21 patients with LMGC who underwent hepatectomy between 1998 and 2007 were assessed. Isolated metastases and potential to perform a curative resection were requisite indi-cations for surgery. Surgical outcome and clinicopathologic features of the hepatic metastases were analysed. Results: Overall 1-, 3- and 5-year survival rates after hepatic resection were 68%, 31% and 19%, respectively; three patients survived for >5 years without recurrence. Univariate analysis revealed a solitary metastasis, negative margin (R0) resection and the presence of a peritumoral fibrous capsule as significant favourable prognostic factors. These characteristics were present in all of the three patients who survived for >5 years. Conclusions: Solitary metastases from gastric cancer should be treated surgically and confer a better prognosis. Surgical resection should provide microscopically negative margins (R0). A new prognostic factor, the presence of a pseudocapsule, may be associated with improved prognosis.

Background Pneumoperitoneum (PP), established for laparoscopic (LPS) operation, has been associated with potential detrimental effects, such as mesenteric ischemia-reperfusion injury. The objective of the trial was to measure intestinal tissue oxygen pressure (PtiO2) and oxidative damage during laparoscopic (LPS) and open colon surgery and during the postoperative course. Methods Forty patients candidate to left-sided colectomy were randomized to undergo open or LPS resection (20 patients/group). During the operation, PtiO2 was measured at established changes of PP pressure (from 0-15 mmHg) and for 6 days postoperatively. P tiO2 was determined by a polarographic microprobe implanted in the colon wall. Ischemia-reperfusion injury was assessed by plasma malondialdehyde (MDA). ClinicalTrial.gov registration number: NCT01040013. Results LPS was associated with a higher PtiO2 at the beginning of surgery (73.9 ± 9.4 vs. 64.3 ± 6.4 in open; P = 0.04) and at the end of the operation (57.7 ± 7.9 vs. 53.1 ± 4.7 in open; P = 0.03). PtiO2 decreased significantly during mesentery traction vs. beginning in both groups (respectively 58.7 ± 13.2 vs. 73.9 ± 9.4 in LPS and 55.3 ± 6.4 vs. 64.3 ± 6.4 in open group; minimum P = 0.02). During LPS, there was a significant decrease of PtiO2 only when PP was increased to 15 mmHg (63.2 ± 7.5 vs. 76.6 ± 10.7 at 10 mmHg; P = 0.03). PtiO2 also was significantly better in the LPS group during the first 3 days after operation (minimum P = 0.04 vs. open). MDA significantly increased in both groups after mesentery traction and at the end of operation vs. baseline levels with no difference between techniques. Conclusions LPS seems to be associated with a better intra- and postoperative PtiO2. High-pressure PP may impair PtiO2.

The outcome of HCC after transplantation (OLT) in children is not well known. Unfavorable features based on adult reports may lead to contraindicate OLT even in children. We reviewed a cohort of children with cirrhosis and HCC to evaluate their outcome after primary transplantation. We considered children with cirrhosis and HCC who had a primary OLT. We retrospectively recorded demographic, medical and surgical features, and MC as predictors of outcome. Among 456 children transplanted in the last 15 yr, 10 (2%), median age at diagnosis 1.8 yr (range 0.5-7.2), had HCC in biliary atresia (3), BSEP deficiency (3), tyrosinemia type 1 (2), complications of choledocal cyst and glycogen storage disease type IV (1 each). At HCC discovery, median AFP was 2322 ng/mL (3-35,000), high or rising in 9/10 patients. Six patients were outside the MC. Median time on the waiting list was 38 days (1-152). Two patients died from early complications of OLT. In the other eight patients, there was no tumor recurrence after a median follow-up of four yr. Children with cirrhosis may develop HCC at a very young age. The outcome appears excellent even outside MC. Primary liver transplantation is advisable for children with cirrhosis, HCC, and no extrahepatic disease.

Profound changes in perioperative management, namely "fast track surgery" have been recently proposed. This is a bundle of various techniques used for subjects undergoing elective operations that allows an improved well-being, faster recovery, shorter hospitalization and better outcome. From a nutritional point of view this new approach translates into a more rapid return of bowel function and thus to safely tolerate oral re-feeding within 1-3 days even after major operations. Nevertheless, the classic indications for perioperative artificial nutritional support remain valid but they should now apply only to a minority of patients.Extensive research in the last 20 years has clearly shown that modifying the composition of standard nutritional feeds by adding supernormal doses of specific substrates that have immuno-modulatory, anti-inflammatory, anabolic, and tissue protective ability often translates into improved surgical outcome. The most convincing and reproducible results were obtained on the reduction of infectious complication by the perioperative use of enteral formulas enriched with arginine and omega-3 fatty acids. (Nutr Hosp. 2011;26:56-67) DOI:10.3305/nh.2011.26.1.4935

AIM: To investigate whether probiotic bacteria, given perioperatively, might adhere to the colonic mucosa, reduce concentration of pathogens in stools, and modulate the local immune function. METHODS: A randomized, double-blind clinical trial was carried out in 31 subjects undergoing elective colorectal resection for cancer. Patients were allocated to receive either a placebo (group A, n = 10), or a dose of 107 of a mixture of Bifidobacterium longum (BB536 ) and Lactobacillus johnsonii (La1 ) (group B, n = 11), or the same mixture at a concentration of 109 (group C, n = 10). Probiotics, or a placebo, were given orally 2 doses/d for 3 d before operation. The same treatment continued postoperatively from day two to day four. Stools were collected before treatment, during surgery (day 0) and 5 d after operation. During the operation, colonic mucosa samples were harvested to evaluate bacterial adherence and to assess the phenotype of dendritic cells (DCs) and lymphocyte subsets by surface antigen expression (flow cytometry). The presence of BB536 and La1 was evaluated by the random amplified polymorphism DNA method with specific polymerase chain reaction probes. RESULTS: The three groups were balanced for baseline and surgical parameters. BB536 was never found at any time-points studied. At day 0, La1 was present in 6/10 (60%) patients in either stools or by biopsy in group C, in 3/11 (27.2%) in group B, and none in the placebo group (P = 0.02, C vs A). There was a linear correlation between dose given and number of adherent La1 (P = 0.01). The rate of mucosal colonization by enterobacteriacae was 30% (3/10) in C, 81.8% (9/11) in B and 70% (7/10) in A (P = 0.03, C vs B). The Enterobacteriacae count in stools was 2.4 (log10 scale) in C, 4.6 in B, and 4.5 in A (P = 0.07, C vs A and B). The same trend was observed for colonizing enterococci. La1 was not found at day +5. We observed greater expression of CD3, CD4, CD8, and naive and memory lymphocyte subsets in group C than in group A with a dose response trend (C > B > A). Treatment didnot affect DC phenotype or activation, but after ex vivo stimulation with lipopolysaccharides, groups C and B had a lower proliferation rate compared to group A (P = 0.04). Moreover, dendritic phenotypes CD83-123, CD83-HLADR, and CD83-11c (markers of activation) were significantly less expressed in patients colonized with La1 (P = 0.03 vs not colonized). CONCLUSION: La1 , but not BB536 , adheres to the colonic mucosa, and affects intestinal microbiota by reducing the concentration of pathogens and modulates local immunity. © 2010 Baishideng. All rights reserved.

OBJECTIVE:: To investigate whether perioperative intravenous glutamine supplementation may affect surgical morbidity. SUMMARY BACKGROUND DATA:: Small-sized randomized trials showed a trend toward a reduction of postoperative infections in surgical patients receiving glutamine. METHODS:: A randomized, multicentre trial was carried out in 428 subjects who were candidates for elective major gastrointestinal surgery. Inclusion criteria were: documented gastrointestinal cancer, weight loss 18 years. Patients received either intravenous infusion of L-alanine-L-glutamine dipeptide (0.40 g/kg/d; equal to 0.25 g of free glutamine) (Ala-Glu group, n = 212), or no supplementation (control group, n = 216). Glutamine infusion began the day before operation and continued postoperatively for at least 5 days. No postoperative artificial nutrition was allowed unless patients could not adequately eat by day 7. Postoperative morbidity was assessed by independent observers according to a priori definition. RESULTS:: Patients were homogenous for baseline and surgical characteristics. Mean percent of weight loss was 1.4 (2.7) in controls and 1.4 (2.4) in Ala-Glu group. Overall postoperative complication rate was 34.9% (74/212) in Ala-Glu and 32.9% (71/216) in control group (P = 0.65). Infectious morbidity was 19.3% (41/212) in Ala-Glu group and 17.1% (37/216) in controls (P = 0.55). The rate of major complications was 7.5% (16/212) in Ala-Glu group and 7.9% (17/216) in controls (P = 0.90). Mean length of hospitalization was 10.2 days (4.8) in Ala-Glu group versus 9.9 days (3.9) in controls (P = 0.90). The rate of patients requiring postoperative artificial nutrition was 13.2% (28/212) in Ala-Glu group and 12.0% (26/216) in controls (P = 0.71). CONCLUSIONS:: Perioperative glutamine does not affect outcome in well-nourished GI cancer patients. Copyright © 2009 by Lippincott Williams & Wilkins

Background and aims: Innate 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 methods: Seventeen 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. Results: Toxicity was moderate. In the early postoperative period, blood NK cells and eosinophils significantly increased compared to basal values (p < 0.02). Histopathological analysis did not find significant intratumoral infiltration of NK cells nor of eosinophils. Conclusions: Preoperative 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. © 2008 Springer-Verlag.

den onset of marked somnolence associated to loss of bladder control, in the absence of fever or other symptoms. Both the head CT scan and routine blood tests (comprehensive of cell blood count, kidney and liver function, and glucose) were uninformative. During observation in the ER, the state of vigilance rapidly deteriorated and clonic movements of both arms were observed; she was promptly treated with ev diazepam with slow remission of the symptoms. Past medical history documented: hysteroannessiectomy with partial removal of the bladder and ureterosigmoidostomy for a suspected endometrial cancer at age 56; and lumbar interlaminar herniectomy at age 67. During the following days of hospitalisation in the neurology ward her vigilance status displayed a peculiar rapidly relapsing–remitting course (see Fig. 1); EEGs were performed on days 2, 9 and 11. At day 9 an abrupt worsening of her vigilance level was observed and, considering it as a manifestation of a non-convulsive status epilepticus, the patient was treated with a phenytoin load. Once the cause was identified, the patient was opportunely treated and monitored, and she was restituted to her previous status. (a) What is the most probable cause of this rapidly cycling course? (b) What single parameter would you assess in blood? Neurol Sci (2008) 29:125–126 DOI 10.1007/s10072-008-0873-x

Cancer-associated immunodeficiency is seriously worsened by surgical trauma. Short-term preoperative interleukin-2 (IL-2) immunotherapy abolishes postoperative immunodeficiency and can induce immunological control of the growth of minimal residual disease. Growth factors play an important role in oncological practice in treating neutropenia (G-CSF) or associated anaemia during chemotherapy (erythropoietin). Unfortunately, lymphocytopenia is not considered a biological marker with regard to survival. On the other hand, the role of the immune response to surgical trauma has been emphasised by many surgeons, and to counteract it immune nutrition (omega 3 fatty acid, mRNA, arginine) or thymic hormone have been tried. We believe that the obvious method of counteracting postoperative lymphocytopenia is the administration of the specific growth factor for T lymphocytes, i.e. IL-2. The aim of this study was to report on our experience with IL-2 preoperative immunoactivation in colorectal cancer and the long-term outcome of patients treated in comparison with a control group operated on without immunotherapy. In order to obtain activated lymphocytosis at the time of operation administration of IL-2 (6 million I.U. twice daily subcutaneously) for 3 preoperative days is sufficient, starting 4 days before surgery. The inclusion/exclusion criteria were histologically documented colorectal cancer, elective surgery, laparotomic surgery, no second tumour, age 20-80 years, no cardiovascular, hepatic or renal failure. From June 1992 to December 2005, 67 patients were treated (Dukes B/C: 46/21) with IL-2 immunotherapy. The clinical and biological results were compared with those of a control group of 173 patients (Dukes B/C 114/59) operated on in the same period and recruited with the same criteria. Dukes stage-C patients in both groups underwent adjuvant chemotherapy plus radiotherapy for rectal cancer. Data were statistically analysed using Fisher's exact test, Student's T-test and analysis of variance, as appropriate. The overall survival curves were plotted with the Kaplan-Mayer method. After a median follow-up of 69 months (range: 12-169) the progression rate was 15/67 (22%) vs 68/173 (39%) in controls (p = 0.02). Important results were obtained in Dukes-B patients: progression rate 7/46 (15%) vs 37/114 (32,4%) in controls (p = 0.03). We can conclude that immunotherapy is well tolerated. IL-2 is capable of counteracting surgery-induced immunodeficiency. The amplification of the immune response in the post-operative period is capable of controlling minimal residual disease after radical surgery, of reducing the progression rate, and of improving the prognosis and overall survival.

OBJECTIVE: Author's experience with periduodenal perforation after ERCP and there systematic approach is presented. METHODS: A retrospective study of 6 instances of duodenal perforation related to endoscopic retrograde cholangiopancreatography. The study follows these parameters: type of perforations, clinical presentation, diagnostic methods, time to diagnosis, methods of management, surgical procedures, length of stay, mortality and morbidity. RESULTS: Traditionally duodenal perforation after ERCP has been managed surgically; however in last decade management has been shifted to a more selective approach, but some authors promotes non surgical routine management: the reported death rate of medical treatment is high as 50%. In our experience an aggressive diagnostically and therapeutically management may reduce mortality. The decision to manage patients without surgery is a dynamic one and should undergo frequent reevaluation whenever the clinical circumstances demonstrate even the slightest untoward development. CONCLUSION: A selective management scheme and an aggressive but selective surgical approach may influence overall mortality

Background: Laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disease of the spleen. Intraoperative bleeding is the main complication and main cause of conversion during LS. In this paper, we present our experience with 112 LS procedures, comparing two different techniques and instruments for spleen dissection and hilar vascular control. Methods: We have performed a total of 112 LS procedures in 9 years in two affiliated university hospitals. There were 48 males and 64 females (median age, 32.8 years). Indications were as follows: idiopathic thrombocytopenic purpura (ITP) in 42 patients, hereditary spherocitosis in 28, 6 with β-talassemia, 1 with hemolitic anemia, 27 with lymphoma, 2 with leukemia, 3 with splenic cysts, and 3 PPT cases. Associated procedures were present in 25 cases (17 cholecystectomy and 4 liver/lymphnodal biopsies + lysis of adhesions). Patients were divided in two groups according to the method of dissection and hilar section (group 1, endostapler + monopolar coagulation with 38 patients; group 2, the Ligasure™ Vessel Sealing System (Valleylab, Boulder, CO) with 74 patients). Results: Groups were well matched according to age, indications, spleen sizes, and procedures associated. Conversion rates (10 cases, 9%; 5 in each group), postoperative hospital stay (median 4 days in each group), and intra- and postoperative complications were similar in the 2 groups without any mortality in each group, while intraoperative blood loss (loss of 100 mL in 55 patients in group 2, 78%; and in 21 patients in group 1, 52%), transfusion rates (8 patients in group 1 versus 4 patients in group 2), and operative mean time (150 minutes in group 1 versus 125 minutes in group 2) were minor in the Ligasure Vessel Sealing System group, with a statistical significance. Conclusions: The approach to spleen dissection and hilum section was safe and efficacy in each case, otherwise the use of Ligasure results in a gain of time. Furthermore the average intraoperative bleeding and average transfusion rates of this series were lower in group 2. © 2007 Mary Ann Liebert, Inc.

Background: There 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. Methods: Sixty-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. Results: Low-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 (P < 0.05). A stepwise multivariate analysis revealed that overall survival and relapse-free survival were affected only by stage of tumor and age of patients. Conclusions: According 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. © 2007 Society of Surgical Oncology.

Carcinoma showing thymic-like elements (CASTLE) is a rare tumor affecting thyroid and neck soft tissues, which has to be distinguished from squamous cell and anaplastic thyroid carcinoma, because it has a better prognosis. We report a new case of CASTLE which occurred in a patient submitted to total thyroidectomy with central neck dissection. The tumor stained positively for CD5, which seems to be the most useful marker in the differential diagnosis. By the analysis of the 18 cases reported in literature, total thyroidectomy with selective modified neck dissection should be the treatment of choice and radiotherapy should be considered for patients with positive nodal status.

Background and aims: Thrombosis of the portal system is a potentially life-threatening complication after splenectomy. The reported incidence is low (≅1%), however may be underestimated due to difficult in making the diagnosis. The factors associated with its development and the clinical outcome are poorly characterized. The aim of this study was to assess the incidence, risk factors, treatment, and outcome in series of consecutive cases. Materials and methods: All patients who had undergone a splenectomy (both open and laparoscopic) between January 1997 and December 2004 at the Department of Surgery of University of Milan Bicocca were retrospectively reviewed. Twelve cases of thrombosis (7.6%) among 158 splenectomies were identified. No significant differences were noted in age, gender, and surgical approach between patients who developed thrombosis and those who did not. Indication for splenectomy in patients with thrombosis were myeloproliferative disorders (n=5), hemolytic disease (n=4), and lymphoproliferative disorder (n=3). All patients had splenomegaly (mean 1.380 kg, range 0.400-3.120 kg). Results: Among patients with myeloproliferative disorders, five (33%) developed the complication, compared with 4 of 35 (11.5%) with hemolytic disease. Patients with both splenic weight >2.500 kg and myeloproliferative disorders had 80% incidence of portal thrombosis. Preoperative prophylactic anticoagulant therapy with low molecular weight heparin was administered in each case. All these patients had fever, abdominal pain, or leukocytosis. All diagnoses were made by contrast-enhanced computed tomography (CT) scan and ecocolordoppler ultrasonography, and anticoagulation therapy was initiated immediately. Treatment within 15 days after splenectomy was successful in all patients, while delayed treatment was ineffective. Conclusions: Portal thrombosis should be suspected in patients with fever or abdominal pain after splenectomy. Patients with myeloproliferative disorders and hemolitic diseases are at higher risk, as well as patients with marked splenomegaly. A high index of suspicion, early diagnosis, and prompt anticoagulation therapy are the keys to a successful outcome. © Springer-Verlag 2006.

We report a case of the contemporaneous presence of two histologically different pancreatic neoplasms, one renal cancer and one embryogenic duodenal anomaly in a single patient. A 66-year-old man underwent ultrasound examination because of urinary disorders; a solid neoformation within the inferior pole of the left kidney was observed. Computed tomography confirmed the renal lesion, but also a heterogeneous mass within the pancreatic head appeared without bile ducts dilatation. Abdominal magnetic resonance revealed a multiloculated cystic component of the pancreatic mass. A second CT scan confirmed the renal and biliary findings, but it revealed a modest enlargement of the pancreatic asymptomatic mass. A resection of the left kidney inferior pole and a pylorus-preserving pancreaticoduodenectomy were performed. Histopathologic analysis of the surgical specimen revealed mild differentiated papillary renal carcinoma, intraductal papillary mucinous adenoma of the pancreatic head, foci of intraepithelial pancreatic neoplasm and pancreatic heterotopy of duodenal muscular and submucosal layers. The coexistence of several primaries and anomalies in one patient led us to suppose a genetic predisposition to different lesions, even in the absence of known familial genetic syndromes. The study of such cases may help to improve the investigation of molecular correlations and etiological factors of different solid tumors. Nowadays, surgery is the only effective cure.

Thrombosis of the portal system is a potentially life-threatening but otherwise underappreciated complication after splenectomy. Nonspecific and mild onset symptoms are the cause of delay in diagnosis, and the short hospital stay after laparoscopic approach could even contribute to the difficulty of early detection of this condition. The aim of this study was to verify if planned imaging controls are able to discover this complication leading to a prompt treatment. Thirty-eight patients (19 males and 19 females with a mean age of 24 years) who underwent laparoscopic splenectomy at our institution were studied to identify clinical signs of thrombosis of the portal venous system and eventually associated factors. All the patients were enrolled in a protocol of imaging surveillance using a doppler ultrasound method. Postoperative thrombosis of the spleno-portal axis occurred in 7 patients (18.9%) of the series. In 3 cases (8.1%) the thrombus extended from the splenic vein to occlude the portal axis. The complication was symptomatic in 4 cases (10.8%), whereas in 3 cases, the thrombosis was an ultrasonographic surprise in totally asymptomatic patients. Thrombosis occurred even as late as 2 months after splenectomy. Splenomegaly was the only significant factor predictive of thrombosis. Only those patients who had an early detection of portal or splenic vein thrombosis had a recanalization of the veins with anticoagulant therapy. Patients with splenomegaly who underwent laparoscopic splenectomy are at risk of thrombosis of the portal system and should undergo strict imaging surveillance and aggressive anticoagulation therapy. Copyright © 2006 by Lippincott Williams & Wilkins.

BACKGROUND/AIMS: Surgery has appeared to induce lymphocytopenia and this decrease in host defenses during postoperative period could promote both the proliferation of possible micrometastases and the implantation of surgically disseminated tumor cells. The aim of this study is to evaluate if the preoperative subcutaneous injection of IL-2 (interleukin-2) may be able to abrogate surgery-induced immunosuppression in radically operable gastric cancer and to assess its toxicity. METHODOLOGY: This phase II study included 39 consecutive patients with histologically proven gastric adenocarcinoma (M/F 26/13; mean age 68; range 48-82) who underwent radical surgery from October 1999 to December 2000. Patients were randomized to be treated with surgery alone as controls (20 patients) or surgery plus preoperative treatment with recombinant human IL-2 (19 patients). IL-2 was administered subcutaneously, at a dose of 9,000,000 IU, for three consecutive days, followed by surgery within 36 hours from IL-2 withdrawal. We considered the total lymphocyte count and lymphocyte subset (CD4, CD4/CD8) during the preoperative period, before IL-2 administration, and on the 14th and 50th day. RESULTS: Two groups were well matched for type of surgery and extent of disease. All the patients underwent radical surgery plus D2 lymphadenectomy. At baseline, there were no significant differences in total lymphocyte and lymphocyte subsets between groups. The control group showed a significant decrease of total lymphocytes, CD4 cells, and CD4/CD8 ratio at the 14th postoperative day relative to the baseline value. Among the 22 patients evaluated in the control group 13 had a decreased of CD4 under 500 cells/mm3 (65%). Instead in the IL-2 group a significant increase was observed over the control group values of total lymphocytes and CD4 cells (14th ly total and CD4: IL-2 vs. control p

Cystic hepatic metastases arising from lung cancer are rare. We herein describe a case of a 71-year-old women admitted to our hospital for abdominal pain 6 months after the resection of a lung adenocarcinoma. Two cystic lesions of the liver were discovered at abdominal ultrasonography and computerized tomography scan. An ERCP excluded a biliary adenoma or adenocarcinoma, and an ultrasound-guided liver biopsy was negative for malignant cells. For persistence of symptoms and lack of a diagnosis, the patient underwent an exploratory laparotomy, a surgical biopsy with a diagnosis of adenocarcinoma, and a consequent right hepatectomy. After 2 years of follow-up, the patient is well and disease free. Although cystic liver metastasis are rare and a differential diagnosis difficult, the malignant nature should always be considered in the differential diagnosis of hepatic cysts to offer the patient the best treatment.

Background Mild, long-term non-compliance with immunosuppressive treatment after organ transplantation is common, and can result in early mortality. One possible source of non-compliance is the belief that the treatment is ineffective or unnecessary. This study investigates patients perception of the efficacy of their immunosuppressive treatment in a sample of heart transplant patients. Methods A questionnaire was given to 67 heart transplant recipients. The first part of the questionnaire addressed health-related behavior and attitude toward the immunosuppressive medication, using self-report questions. In the second part of the questionnaire, participants evaluated the perceived risk of rejection associated with non-compliant behaviors described in 8 scenarios. Results The data from the self-report questions showed a mild level of behavioral non-compliance, increasing over time, and a mild level of medication non-compliance. One third of the medication non-compliant patients chose the inefficacy or non-necessity of the treatment as a main cause of non-compliance. The second part of the questionnaire showed that subjective perceived efficacy of the immunosuppressive treatment decreased over time. Conclusions Medication non-compliance is fostered by many factors. One of these is the belief that the treatment is ineffective or unnecessary. This belief increases over time, and could be the result of a non-clinical selective-attention bias. J Heart Lung Transplant 2003; 22:000–000.

The effectiveness of perioperative administration of thymopentin in preventing postoperative infection was evaluated in 206 patients with cancer (54 gastric, 152 colorectal) who underwent elective major surgery. Comparable subsets of patients were obtained with respect to age (proportion over 65 years) and nutritional status (patients with serum albumin level less than 30 g/l or weight loss of 10 per cent or more of usual body-weight were considered to be malnourished). Patients were then randomly assigned to a control group or to a group receiving thymopentin. All patients received perioperative short-term antibiotic prophylaxis and postoperative parenteral nutrition. Levels of CD3-, CD4- and CD8-positive T cell subsets were evaluated before and after surgery in 20 (ten elderly) patients from each group. The severity of postoperative infection was evaluated using a sepsis score. In elderly patients thymopentin prevented the postoperative drop in CD3- and CD4-positive T cell subpopulations that was observed in controls (P < 0·05). The postoperative infection rate was 17·5 per cent in the group given thymopentin and 24·3 per cent in controls (P not significant). The mean(s.d.) sepsis score was 6·7(3·1) in the group receiving thymopentin and 9·4(5·8) in controls (P not significant). Considering only elderly patients, the mean(s.d.) sepsis score was significantly lower in those treated with thymopentin than in control patients (6·9(2·1) versus 11·3(4·7)). In conclusion, administration of thymopentin did not significantly reduce the postoperative infection rate. However, it prevented the drop in number of CD3- and CD4-positive T cells after operation and reduced the severity of postoperative infection in elderly patients.

The ability of perioperative short-term antibiotic prophylaxis to reduce the predictive significance of nutritional indicators for postoperative infections was evaluated in 162 patients undergoing major surgery for gastric or colorectal cancer. All patients were randomly assigned to a group receiving such prophylaxis or a group with postoperative antibiotic treatment. Preoperative serum albumin, total iron-binding capacity and weight loss were the nutritional indicators, and the evaluation included delayed hypersensitivity response. Postoperative infections occurred in 29% of the total series, with highest incidence in the group with postoperative antibiotics (p less than 0.001) and in anergic patients (p less than 0.05). Increased risk of postoperative infection was related also to the number of altered nutritional indicators (p less than 0.005). Multiple logistic analyses showed that the short-term prophylaxis independently contributed to fall in the infection rate and reduced the prognostic importance of nutritional and immunologic factors. Indeed, heightened incidence of postoperative infection was found only when all three nutritional factors were altered.

Introduction Predicting long-term survival and cancer recurrence in patients with colorectal cancer is difficult because of the many factors that may affect the prognosis. This study investigated the prognostic significance of postoperative infections for patient outcome. Methods From an electronic database we selected 192 patients undergoing elective radical surgery for Dukes’ stage B and C colorectal adenocarcinoma. The five-year survival rates were analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were carried out to evaluate the potential prognostic variables using the Cox proportional hazard model. Results Forty-three patients developed deep incisional or organ/space surgical site infections, while the remaining 149 were complication free. The two groups were comparable for baseline, surgical and histopathological characteristics. At univariate analysis, Dukes’ stage and infections were negative prognostic factors, while peritumoral infiltration of lymphocytes and eosinophils and fibrotic tissue appeared as protective variables. However, multivariate analysis showed that only Dukes’ stage (P = 0.048) and occurrence of postoperative infectious complications (P = 0.011) were independently associated with outcome. In patients with infectious complications, the survival rate was significantly lower than in patients without infections (log-rank = 0.0004). Conclusions The present results suggest the importance of evaluating other variables besides tumor stage in the prediction of long-term outcome. In prognostic studies more attention should be paid to postoperative infections.

The efficacy of thymopentin in reducing postoperative infections (PI) was prospectively evaluated in 138 patients with abdominal cancer, who underwent major surgery. Comparable subsets of patients were obtained according to age (cutpoint 65 years) and nutritional status (patients with serum albumin less than 30 g/l or weight loss greater than or equal to 10% with respect to their usual body weight were considered as malnourished). Patients were then at random attributed to a control group and to a thymopentin receiving (Thy) group, in the latter thymopentin (50 mg) was given three times before surgery and three times after operation. All patients received perioperative short term antibiotic prophylaxis and postoperative parenteral nutrition. The severity of Pl was expressed by the sepsis score which was calculated on all those patients developing Pl. Overall complication rate was 26.3% in the control group and 20.3% in the Thy group (p ns). Surgical-related infections occurred in 14 (20.3%) control group patients and in 10 (14.5%) Thy group patients (p ns). The average sepsis score was 10.11 +/- 6.69 in control group (2 patients died) and 6.85 +/- 3.80 in the Thy group (all patients survived) (p less than 0.05). By considering the elderly patients, a reduction in both Pl rate and the average sepsis score was observed in Thy group. Otherwise, no difference was observed in the young patients. Our data suggest that Thymopentin is useful in reducing both the incidence and the severity of Pl in elderly patients.

Interactions between host and malignant tumor is currently under intensive investigation. The immune system seems to have a key role in cancer development and spread. Novel strategies to actively modulate the immune system have been proposed to improve the outcome of disease in patients with neoplasms. Our experience with systemic immunomodulation by interleukin-2 (IL-2) focused on both systemic and local immunity in surgical gastrointestinal cancer. Preoperative IL-2 subcutaneous injection was effective in counteracting postoperative immunosuppression, with a reduction of serum levels of IL-6 and the maintenance of preoperative levels of IL-12, a higher number of circulating total lymphocytes, and CD3(+) and CD4(+) T-cells, and a smaller decrease in circulating mature and immature dendritic cells (DCs), as well as a reduction in postoperative serum levels of vascular endothelial growth factor. At the intestinal level, in patients with colorectal cancer, preoperative administration of IL-2 affected both phenotype and function of resident dendritic cells and T-cells, skewing local immunity toward a more immunogenic one. Our data showed that immunomodulation by IL-2 was effective in counteracting the systemic postoperative immune suppression related to surgical stress. IL-2 was also active at a local level on intestinal immunity, affecting both phenotype and function of resident T-cells and DCs. Future studies will encompass the possibility of reaching more adequate intratumoral IL-2 concentrations by direct intralesional injection to maximize immunostimulatory effects and minimize adverse effects.

Context Pancreatic cystic lesions are increasingly recognized and comprise different pathological entities. The management of these lesions is challenging, because of inadequate preoperative histological diagnosis. Among this family of lesions, mature cystic teratomas are an extremely rare finding. Case report We present the case of a 61-year-old man with a mature cystic teratoma of the pancreas’ uncinate process, incidentally discovered at diagnostic imaging. Conclusions This case highlights the difficulty to obtain a preoperative diagnosis of this pathological entity and the need of increased awareness about mature cystic teratoma when examining a pancreatic cystic lesion., JOP. Journal of the Pancreas, Vol 13, N° 1 (2012): January - p. 1-123