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Complete mesocolic excision (CME) has introduced a promising surgical approach for treatment of right colon cancer. However, benefits of CME are still a matter of debate. We conducted a systematic review and meta-analysis to assess safety and long-term outcomes of CME versus conventional right hemicolectomy (CRH). We systematically searched MEDLINE, the Cochrane Database of Systematic Reviews, Scopus, Web of Science, and Embase for retrieving studies comparing CME with CRH in right colon cancer. After data extraction from the included studies, meta-analysis was performed to compare postoperative complications, anastomotic leakage, 30-day mortality, number of lymph node yield, disease-free survival (DFS), and overall survival (OS). Eight studies met the inclusion criteria with a total of 1871 patients enrolled. No difference was observed in postoperative complications (OR 1.13, 95% CI 0.88–1.47, p = 0.34). CME was associated with significantly higher number of lymph nodes retrieved (MD 9.17, CI 4.67–13.68, p

Background Despite improvements in surgical techniques and perioperative management, post-operative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). The aim of this study was to evaluate the role of perioperative clinical variables of patients, including albumin level, in predicting pancreatic fistula. Methods A total of 86 patients underwent PD for pancreas cancer between 2011 and 2017 at our institution. We prospectively investigated the relation between patient's characteristics and the incidence of clinically relevant (CR)-POPF. Perioperative albumin ratio was defined as post-operative day 1 (POD1) albumin level/preoperative albumin level. Results A total of 23 patients (26.7%) developed CR-POPF. At univariate analysis POPF correlated with soft pancreas (P = 0.045), low POD1 albumin (P = 0.02), POD1 and POD3 amylase levels in drainage fluid (P = 0.003 and P = 0.014, respectively) and perioperative albumin ratio (0.58 ± 0.10 versus 0.69 ± 0.12 in patients without POPF; P = 0.003). No significant correlations with POPF were demonstrated for surgical time, serum amylase levels and preoperative albumin levels. At multivariate analysis POD3 amylase level in drainage fluid and perioperative albumin ratio were the only significant independent parameters (P = 0.027 and P = 0.047, respectively). Conclusions Perioperative albumin ratio can predict POPF after PD.

BACKGROUND Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal and external rectal prolapse with obstructed defecation syndrome (ODS) and/or fecal incontinence. The aim of our study was to analyze functional outcome and quality of life (Health-Related Quality of Life) after LVR for symptomatic internal prolapse and/or rectocele with ODS. METHODS Prospectively collected data on LVR for internal rectal prolapse were analyzed in 50 consecutive female patients operated between January 2011 and December 2018. In all cases, we performed a LVR according to the D'Hoore technique. Patients had ODS and internal rectal prolapse (grade 3 or 4) confirmed at the defecogram study. We registered only 1 major complication that required surgical treatment (Clavien-Dindo IIIb). The median hospital stay was 4 days [interquartile range (IQR): 2 to 5 d]. Functional results were measured with the Wexner Constipation Score and the 36-Item Short-Form Health Survey, and were analyzed before surgery and after 3, 6, or 12 months. RESULTS After a median follow-up of 16.5 months (IQR: 10 to 44.25 mo), the Wexner Total Score was significantly improved in almost all items passing from 14 (IQR: 11 to 18) to 11 (IQR: 6.25 to 14.75) after surgery (P

Summary Introduction Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group. Methods Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80 years of age, and group 2, patients 80 years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians. Results There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications’ rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19 months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients. Conclusion Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory.

Background Risk of surgery is among the highest-rated concerns among Crohn’s disease (CD) patients. Quality of life is often worsened by intestinal surgery. This study aimed to assess the possible predictors of long-term quality of life after minimally invasive surgery for ileal, colonic or ileocolonic CD. Methods Data of all the 72 consecutive patients operated from 2010 to 2018 for CD were retrieved and 72 patients who had ileal, colonic or ileocolonic resection were selected and interviewed with the Cleveland Global Quality of Life (CGQL) questionnaire and the Body Image Questionnaire (BIQ). Disease activity was defined as the Harvey–Bradshaw Index (HBI). Comparisons between laparoscopic and open groups were carried out with non-parametric tests and log-rank test. Results Seventy-two patients who had laparoscopic ileal, colonic or ileocolonic resection and had a follow-up greater than 1 year were interviewed. The total CGQL score was associated with clinical disease activity at the moment of the interview (rho = −0.61, p < 0.0001) and to the presence of extraintestinal complication (rho = 0.28, p = 0.03). At multivariate analysis, disease activity at the moment of the interview and the presence of extraintestinal complication confirmed to be independent predictors of long-term quality of life. Conclusion Long-term quality of life after minimally invasive intestinal surgery is essentially predicted by current disease activity. Thus, it is crucial to prevent clinical CD recurrence

AIM To analyze the importance of para-aortic node status in a series of patients who underwent pancreaticoduodenectomy (PD) in a single Institution. METHODS Between January 2000 and December 2012, 151 patients underwent PD with para-aortic node dissection for pancreatic adenocarcinoma in our Institution. Patients were divided into two groups: patients with negative PALNs (PALNs-), and patients with metastatic PALNs (PALNs+). Pathologic factors, including stage, nodal status, number of positive nodes and lymph node ratio, invasion of para-aortic nodes, tumor’s grading, and radicality of resection were studied by univariate and multivariate analysis. Survival curves were constructed with Kaplan-Meier method and compared with Log-rank test: significance was considered as P < 0.05. RESULTS A total of 107 patients (74%) had nodal metastases. Median number of pathologically assessed lymph nodes was 26 (range 14-63). Twenty-five patients (16.5%) had para-aortic lymph node involvement. Thirty-three patients (23%) underwent R1 pancreatic resection. One-hundred forty-one patients recurred and died for tumor recurrence, one is alive with recurrence, and 9 are alive and free of disease. Overall survival was significantly influenced by grading (P = 0.0001), radicality of resection (P = 0.001), stage (P = 0.03), lymph node status (P = 0.04), para-aortic nodes metastases (P = 0.02). Multivariate analysis showed that grading was an independent prognostic factor for overall survival (P = 0.0001), while grading (P = 0.0001) and radicality of resection (P = 0.01) were prognostic parameters for disease-free survival. Number of metastatic nodes, node ratio, and para-aortic nodes involvement were not independent predictors of disease-free and overall survival. CONCLUSION In this experience, lymph node status and para-aortic node metastases were associated with poor survival at univariate analysis, but they were not independent prognostic factors.

Primary leiomyosarcoma is a rare malignant neoplasm, although it is the most common primary pancreatic sarcoma [1]. It accounts for 0.1 % of malignant pancreatic neoplasms [2], and it seems to arise from smooth muscle cells of ducts or blood vessels within the pancreas [3] Pancreatic leiomyosarcoma is a highly aggressive neoplasm in which widespread metastases occur frequently and the liver is typically affected [4], so the prognosis is generally bad [5]. Radical resection of the primary lesion seems to offer the best possibility for cure [6]. We report a case of primary leiomyosarcoma of the pancreas with synchronous hepatic metastases occurring in a 54-year-old female who was treated with repeated surgical excision together with different chemotherapeutic regimens.

To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD).AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly.We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5-12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P.001).AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

Recent studies have correlated physical activity with a better prognosis in cachectic patients, although the underlying mechanisms are not yet understood. In order to identify the pathways involved in the physical activity-mediated rescue of skeletal muscle mass and function, we investigated the effects of voluntary exercise on cachexia in colon carcinoma (C26)-bearing mice. Voluntary exercise prevented loss of muscle mass and function, ultimately increasing survival of C26-bearing mice. We found that the autophagic flux is overloaded in skeletal muscle of both colon carcinoma murine models and patients, but not in running C26-bearing mice, thus suggesting that exercise may release the autophagic flux and ultimately rescue muscle homeostasis. Treatment of C26-bearing mice with either AICAR or rapamycin, two drugs that trigger the autophagic flux, also rescued muscle mass and prevented atrogene induction. Similar effects were reproduced on myotubes in vitro, which displayed atrophy following exposure to C26-conditioned medium, a phenomenon that was rescued by AICAR or rapamycin treatment and relies on autophagosome-lysosome fusion (inhibited by chloroquine). Since AICAR, rapamycin and exercise equally affect the autophagic system and counteract cachexia, we believe autophagy-triggering drugs may be exploited to treat cachexia in conditions in which exercise cannot be prescribed. Recent studies have correlated physical activity with a better prognosis in cachectic patients, although the underlying mechanisms are not yet understood. In order to identify the pathways involved in the physical activity-mediated rescue of skeletal muscle mass and function, we investigated the effects of voluntary exercise on cachexia in colon carcinoma (C26)-bearing mice. Voluntary exercise prevented loss of muscle mass and function, ultimately increasing survival of C26-bearing mice. We found that the autophagic flux is overloaded in skeletal muscle of both colon carcinoma murine models and patients, but not in running C26-bearing mice, thus suggesting that exercise may release the autophagic flux and ultimately rescue muscle homeostasis. Treatment of C26-bearing mice with either AICAR or rapamycin, two drugs that trigger the autophagic flux, also rescued muscle mass and prevented atrogene induction. Similar effects were reproduced on myotubes in vitro, which displayed atrophy following exposure to C26-conditioned medium, a phenomenon that was rescued by AICAR or rapamycin treatment and relies on autophagosome-lysosome fusion (inhibited by chloroquine). Since AICAR, rapamycin and exercise equally affect the autophagic system and counteract cachexia, we believe autophagy-triggering drugs may be exploited to treat cachexia in conditions in which exercise cannot be prescribed.

The natural history of carotid occlusion (CO) has generally been analyzed in the presence of a contralateral patent but diseased internal carotid artery (ICA). Few previous studies have focused on the fate of CO contralateral to the side of a prior carotid endarterectomy (CEA). The aim of this study was to analyze the mortality rate and the incidence of cerebrovascular events in the hemisphere ipsilateral to CO (HICO) in patients who had undergone contralateral CEA. The 30-day and long-term outcomes of 153 consecutive patients who had CEA for severe symptomatic and asymptomatic ICA lesions contralateral to a symptomatic or asymptomatic CO over a 15-year period were considered. The endpoints of the study were mortality and neurological events in the HICO. Overall, the 30-day mortality and stroke rates were 0.6% (1/153) and 1.9% (3/153), respectively; the only death was stroke-related and the stroke was ipsilateral to the operated side. The other 2 strokes were ipsilateral to a symptomatic CO. The follow-up was completed for all patients (mean, 7.7 years; range, 1-172 months). Overall, there were 4 late strokes (2.6%), one of them lacunar in a patient with a symptomatic CO, whereas the other 3 were atheroembolic and ipsilateral to the operated ICA. The risk of late stroke in the HICO at 5 and 12 years was 2%. Overall, there were 19 late deaths, none of them stroke-related. CO, with or without symptoms, contralateral to CEA could be considered a locally benign condition in the long term.

The aim of the present study was to determine the outcome of patients undergoing pancreatic resection with (VR+) or without (VR−) mesenteric-portal vein resection for pancreatic carcinoma. Between January 1998 and December 2012, 241 patients with pancreatic cancer underwent pancreatic resection: in 64 patients, surgery included venous resection for macroscopic invasion of mesenteric-portal vein axis. Morbidity and mortality did not differ between the two groups (VR+: 29% and 3%; VR−: 30% and 4.0%, resp.). Radical resection was achieved in 55/64 (78%) in the VR+ group and in 126/177 (71%) in the VR− group. Vascular invasion was histologically proven in 44 (69%) of the VR+ group. Survival curves were not statistically different between the two groups. Mean and median survival time were 26 and 15 months, respectively, in VR− versus 20 and 14 months, respectively, in VR+ groupp=0.52. In the VR+ group, only histologically proven vascular invasion significantly impacted survivalp=0.02, while, in the VR− group, R0 resectionp=0.001and tumor’s gradingp=0.01significantly influenced long-term survival. Vascular resection during pancreatectomy can be performed safely, with acceptable morbidity and mortality. Long-term survival was the same, with or without venous resection. Survival was worse for patients with histologically confirmed vascular infiltration.

Carotid endarterectomy (CEA) reduces the risk of stroke in selected patients with symptomatic and asymptomatic carotid disease, but its beneficial influence on cognitive performance in the elderly remains debatable. This prospective study sought to determine early and long-term neurocognitive outcomes after CEA for severe unilateral carotid artery stenosis.From July 2006 to December 2008, 75 symptomatic (group A) and 70 asymptomatic patients (group B) aged 65 years and older underwent CEA under general anesthesia. Sixty-eight age- and sex-matched individuals who underwent laparoscopic cholecystectomy during the same period at our institution served as a control group (group H). Patients with contralateral severe carotid stenosis or occlusion and those with dementia, depression, or a history of major stroke were excluded. Cognitive function was assessed using 2 neuropsychological tests (the Mini-Mental State Examination [MMSE] and the Montreal Cognitive Assessment [MoCA]) performed preoperatively (T0) and then 3 (T1) and 12 months (T2) after operation. A change of at least 2 points between the scores at T0 and T2 was arbitrarily considered as clinically significant.At T0, group A revealed significant cognitive impairments in both mean test scores by comparison with group H (P = .005 and P.01, respectively), whereas there were no significant differences between groups A and B, or between groups B and H. Postoperatively, symptomatic patients had significant improvements in their mean cognitive performance scores in both tests (P.01 and P.01, respectively), whereas there were no changes in the asymptomatic and control patients' scores. No significant differences emerged for the MMSE scores in the 3 groups, whereas there was a marginally significant difference in the MoCA scores between groups A and H (P = .08), but not for A versus B or B versus H when clinically significant scores were considered.Our study showed that only elderly symptomatic patients with severe carotid lesions had a significant improvement in cognitive performance scores after CEA, although the benefit was considered clinically not significant. This suggests that CEA does not diminish neurocognitive functions, but it might provide some protection against cognitive decline in the elderly.

ObjectiveThe aim of this study was to identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA).MethodsA prospectively compiled computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The end point was any neck bleeding after eCEA. End point predictors were identified by univariate analysis.ResultsOf 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were five major and three minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), of which 69 (4.7%) needed re-exploration. Univariate analysis (odds ratio [95% confidence interval]) identified preoperative antiplatelet treatment with clopidogrel (1.77 [1.20-2.62], P = .004), particularly when continued to the day before CEA (3.84 [2.01-7.33], P < .001), and postoperative hypertension (9.44 [6.34-14.06], P < .001) as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], P = .001; 15.27 [2.08-104.43], P = .006, and 2.44 [1.12-5.30], P = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus acetylsalicylic acid (12.00 [2.59-56.78], P = .005), acetylsalicylic acid alone (4.37 [1.99-9.57], P < .001), and ticlopidine (2.49 [1.10-5.63], P = .02) only when they were continued to the day before CEA. No neck bleeding was associated with preoperative treatment with dipyridamole or warfarin, or no medication. No further complications occurred in the patients who underwent re-exploration.ConclusionsThe results of this single-center university hospital study show that neck bleeding after CEA is relatively common but is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.

Background In 1996, the overall prevalence of diabetic patients was 120 million and it will more than double by the year 2025. The most important complication in these patients is the diabetic foot (sepsis, abscess etc.). The aim of this study was to assess the role and results of surgery, performed in emergency or deferred emergency, in older population affected by acute septic foot.

Background Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study aims to examine the long-term outcome in terms of amputations and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology.

Background Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, hence various cerebral protection strategies, including pharmacological management and routine or selective shunting, are commonly available. This study aimed to analyze the results of CEA with intraoperative electroencephalographic (EEG) monitoring to identify factors associated with EEG changes consistent with cerebral ischemia which needed shunting. Methods A prospectively compiled, computerized database of all primary CEAs performed at our institution with EEG monitoring for symptomatic or asymptomatic severe carotid lesions between January 1990 and June 2009 was analyzed. Results In all, 1,914 CEA procedures were performed on 1,696 patients, of which 218 had staged bilateral CEAs. EEG changes were recorded in 392 patients (20.5%), but a shunt was inserted during 312 CEA procedures (16.3%). Multivariate analysis showed that a symptomatic presentation (odds ratio [OR], 1.37; 95% confidence intervals [CI], 1.07-1.76; p = 0.012), prior stroke (OR, 2.28; 95% CI, 1.66-3.13; p < 0.001), contralateral carotid occlusion (OR, 2.14; 95% CI, 1.18-3.91; p = 0.019), and moderate (

Background Elderly population in Western countries is rapidly increasing. Literature suggests that radical colorectal resection in the elderly can be safely undertaken with good short and long term results; however results of specific rectal laparoscopic resections are not well defined and so quality of life. The aim of this study was to assess long-term outcome; risk factors and health related quality of life (HRQoL) in elective rectal cancer laparoscopic resection in patients older than 65 years.

Background The purpose of this study was to analyze our experience of bypass procedures to an isolated (“blind”) popliteal artery segment (IPAS) to revascularize the perigeniculate arteries in patients with critical limb ischemia (CLI), to establish whether such revascularizations could yield acceptable results in terms of patency and limb salvage (LS) rates. Methods Over a decade, 347 above-knee arterial revascularizations were performed in 293 patients and in 51 (14.7%) of these the outflow vessels were the perigeniculate arteries arising from an IPAS, through a reversed saphenous vein or spliced veins ( n = 30, 58.8%; group I) or polytetrafluoroethylene ( n = 21, 41.2%; group II) prosthetic grafts. Patency, LS, and survival rates were assessed using Kaplan-Meier life-table analysis. A complete follow-up (range, 0.1–10.4 years; mean, 5.6 years) was obtained in 49 patients. Results The IPAS was chosen as the last resort in 39 patients (76.5%) because no other infrapopliteal artery was identified as being available at angiography; in 12 patients (23.5%) it was chosen because of an invasive foot infection or ischemic necrosis overlying the dorsalis pedis or the posterior tibial arteries. The study series was mainly male, with significantly more younger patients in group I (72 ± 1 years vs 74 ± 5 years, P = .037). Group I had a statistically higher incidence of diabetes mellitus (76.6% vs 47.6%, P = .033), insulin dependence (56.7% vs 28.6%, P = .047) and history of smoking (80% vs 47.6%, P = .016) than group II. None of the patients died in the perioperative period. There were 3 early graft failures (2 in group I), prompting 3 major amputations. Kaplan-Meier analysis identified 5-year patency and LS rates of 51.4 ± 9.6% and 90 ± 4.3%, respectively, in the series as a whole, and the 2 groups had comparable 5-year patency, LS and survival rates. Conclusion Revascularizations to an IPAS can be performed with acceptable results in terms of patency and LS rates, even when there is no infrapopliteal runoff vessel. Finding perigeniculate arteries arising from an IPAS with no tibio-peroneal vessel reconstitution at arteriography does not justify a pessimistic attitude to the performance of such revascularizations for LS.

Background This study aimed to determine the natural history of common iliac arteries (CIAs) after elective open infrarenal abdominal aortic aneurysm (AAA) repair with an aorto-aortic prosthetic graft. Methods All patients who had a straight tube graft inserted during elective AAA repair at our institution between 1995 and 2005 were prospectively followed up with preoperative and postoperative computed tomography (CT) scans to monitor changes in CIA diameter; their latest CT scan was performed in 2007. Based on preoperative CIA diameter, patients were divided into groups A (both CIAs normal, up to 12 mm in diameter), B (at least 1 ectatic CIA, 13–18 mm), and C (at least 1 aneurysmal CIA, 19–25 mm). The mean follow-up was 7.1 years (range, 2.1–12.3 years). Results Among 201 patients eligible for the study, 92 patients (45.8%) were in group A, 63 patients (31.3%) were in group B, and 46 patients (22.9%) were in group C. Overall, the diameter increased in 119 CIAs (29.6%) by a mean of 1.1, 1.8, and 2.4 mm in groups A, B, and C, respectively. In all, 14 CIAs (5.4%) progressed from “normal” to “ectatic,” and 9 CIAs (10.2%) progressed from “ectatic” to “aneurysmal.” Three aneurysmal CIAs slightly exceeded the 25-mm threshold, but none of these were repaired. No patients showed a progression or development of occlusive iliac artery disease or required repeat operation because of excessive CIA enlargement. Conclusions This analysis showed that most CIAs do not expand after tube graft insertion during AAA repair, and when they do, the degree of dilation is minimal. Tube graft insertion during AAA repair is justified even for ectatic or moderately aneurysmal CIAs, and the procedure is safe and durable. The skepticism surrounding its selective use instead of a systematic bifurcated graft placement seems to be unwarranted.

ObjectiveThis study evaluated (1) elective open abdominal aortic aneurysm repair (OAR) in patients aged ≥80 years before and after stent graft devices for endovascular aneurysm repair (EVAR) became commercially available and (2) the effect on perioperative (30-day) outcome of the anatomic constraints that led to EVAR being excluded for many of them.MethodsA review was conducted on the records of 111 patients aged ≥80 years who underwent elective OAR during a 14-year period at the University of Padua School of Medicine. Patients were separated into two groups: group 1 (n = 65) had OAR before and group 2 (n = 46) after an EVAR program was adopted at the medical school in mid-2000. Perioperative death and morbidity, location of proximal aortic clamp, management of the left renal vein, associated iliac aneurysmal or occlusive diseases, the type of surgical reconstruction, operating time, and lengths of stay in the intensive care unit and the hospital were recorded. All the data were compared between the two groups.ResultsRetroperitoneal approach, suprarenal clamping, left renal vein division, and longer operating room time were statistically more common in group 2 (36.9% vs 12.3%, P = .002; 15.2% vs 3.1%, P = .032; 23.9% vs 7.7%, P = .026; and 117 ± 8 min vs 95 ±7 min, P < .001, respectively). Although group 2 had significantly more iliac aneurysms (52.1% vs 32.3%; P = .036), the number of bifurcated reconstructions was comparable. The overall perioperative mortality rate was 1.8% (2 of 111), and the figures for groups 1 and 2 were comparable (3.1% vs 0%; P = .510). No deaths were cardiac related. Group 2 had a significantly higher incidence of kidney failure (8.7% vs 0%; P = .027). Kaplan-Meier analysis showed an overall 3-, 5-, and 10-year survival rate of 80.6%, 67.2%, and 59.4%, respectively, with a 3- and 5-year survival rate comparable between groups 1 and 2 (77.8% and 66.7% vs 87.8% and 45.8%, respectively; log-rank test, P = .921).ConclusionsOctogenarians can tolerate OAR with acceptable rates of perioperative mortality and morbidity. Although the complexity of OAR has increased significantly in the era of EVAR, the perioperative outcome has not changed.

increased by more than $10,000 with each severity grade of ISGPS DGE (p

Background Skeletal muscle is the major reservoir of body proteins and it can be affected in conditions associated to altered protein turnover and metabolism such as cancer. Although severe wasting is seen primarily in patients with advanced malignancy, some of them present degree of wasting at the onset of disease. Autophagy has been recently described to play a relevant role inmuscle wasting.Materials andMethodsWeperformedmorphometric studies and immunohistochemical analyses on intraoperative rectus abdominis muscle biopsies from 50 consecutive weight stable colorectal patients and 25 weight-stable patients operated for non-inflammatory benign diseases with no clinical signs of myopathies. Biochemical and molecular analyses have been performed in order to evaluate protein profile, the presence of autophagy induction and their correlation with clinical outcome. Results In cancer patients, we observed a subclinical myopathy characterized by an abnormal distribution of myonuclei relocated from the periphery inside themyofiber. The percentage ofmyofibers with abnormally located myonuclei was significantly higher in patients (median= 9%) compared to controls (median= 2.7%) (p=0.0002). Analyses on serum samples showed that, in the absence of systemic inflammation, in the prevalence of cancer patients the levels of albumin and prealbumin were below the normal range and the mean value was significantly lower compared to that detected in controls (albumin: 34.82 ± 5.8 g/L vs 45.2 ± 5.3, p< 0.01; prealbumin: 174.38±57.86 mg/L vs 264.00±69.73, p

Background Skeletal muscle is the major reservoir of body proteins and it can be affected in conditions associated to altered protein turnover and metabolism such as cancer. Although severe wasting is seen primarily in patients with advanced malignancy, some of them present degree of wasting at the onset of disease. Autophagy has been recently described to play a relevant role in muscle wasting. Materials and Methods We performed morphometric studies and immunohistochemical analyses on intraoperative rectus abdominis muscle biopsies from 50 consecutive weight stable colorectal patients and 25 weight-stable patients operated for non-inflammatory benign diseases with no clinical signs of myopathies. Biochemical and molecular analyses have been performed in order to evaluate protein profile, the presence of autophagy induction and their correlation with clinical outcome. Results In cancer patients, we observed a subclinical myopathy characterized by an abnormal distribution of myonuclei relocated from the periphery inside the myofiber. The percentage of myofibers with abnormally located myonuclei was significantly higher in patients compared to controls. Analyses on serum samples showed that, in the absence of systemic inflammation, in the prevalence of cancer patients the levels of albumin and prealbumin were below the normal range and the mean value was significantly lower compared to that detected in controls. Molecular analyses showed an accumulation of p62, a typical marker of autophagy induction, significantly higher in cancer patients compared to controls. We found an inverse correlation between the number of abnormally nucleated myofibers and the presence of lymph node metastasis. Cancer relapse was correlated with low serum levels of prealbumin and high levels of p62 in myofibers of cancer patients. Conclusions Colorectal cancer patients have a subclinical myopathy characterized by myofibers with internally located myonuclei. In the absence of inflammation, cancer patients show low levels of prealbumin and albumin as markers of altered protein turnover and persistent high levels of p62 in myofibers as expression of autophagy induction with an impairment in physiological autophagic flux. Up to now our data indicate that skeletal muscle fibers show nuclear abnormalities that seems to be associated to a better prognosis, while the presence of an altered protein turnover at an early stage of disease, with an impairment in the physiological autophagic flux, that could be predictive of cancer relapse and onset of cancer cachexia.

Primary extra-gastrointestinal stromal tumor (EGISTs) arising in the pancreas is extremely rare: only 20 cases have previously been reported in the English literature from 2000 to 2013. We reported a case of EGIST of the pancreas in a 69-year-old woman who presented with abdominal pain and with a solid, heterogeneously enhancing neoplasm in the uncinate process of the pancreas, revealed preoperatively by an abdominal computed tomography scan. A diagnosis of neuroendocrine tumor was suggested. Positron emission tomography with 68Ga-DOTATOC did not show pathological accumulation of the tracer in the pancreas. The patient underwent enucleation, under ultrasonic guidance, of the pancreatic tumor that emerged to the surface of the pancreas. Histopathology and immunohistochemical examination confirmed the final diagnosis of EGIST of the pancreas (CD117+), with one mitosis per 50 high-power fields. Although rarely, GIST can involve the pancreas as a primary site, and this tumor should be considered in the differential diagnosis of pancreatic neoplasms.

Background Skeletal muscle in patients with cancer undergoes many morphological changes due to immuno-inflammatory factors of tumor origin and/or to the pharmacologic treatment of the disease. The latest event of these changes is cancer cachexia. The aim of our study was to investigate the clinical characteristics and the histopathologic features of skeletal muscle and excised tumor from patients affected with colorectal cancer at diagnosis in order to possibly identify clinical factors associated to myopathic features that could be used as predictive biomarkers of disease progression. Patients and methods Morphometric studies and immunohistochemical analyses were performed on intraoperative rectus abdominis muscle biopsies from weight stable patients with an early diagnosis of colorectal cancer, before systemic or radiant therapies, with no signs of muscle weakness or myopathies. The correlation between histopathologic findings of skeletal muscle biopsies, resected tumor, and clinico-serological characteristics was investigated. Results 44 patients and 17 controls affected with non-inflammatory benign diseases, were recruited for the study. In the skeletal muscle biopsies from cancer patients, we observed a subclinical myopathy characterized by an abnormal distribution of myonuclei relocated from the periphery inside the myofiber, and by the presence of regenerating muscle fibers. The percentage of myofibers with abnormally located myonuclei was significantly higher in patients (median= 9%) compared to controls (median= 2.7%) (p=0.0002). Moreover, the percentage of regenerating myofiber expressing the MHC-emb and N-CAM biomarkers was higher in patients compared to controls (MHC-emb positive 14,6 % vs 5,9% p=n.s; N-CAM positive 31,7 % vs 5,9%, p= 0.04) (Tab I). No correlations were found between the histopathological findings of the skeletal muscle and clinico-serological characteristics of the patients. We found an inverse correlation between the number of abnormally nucleated myofibers and the presence of lymph node metastasis (N+) (n)=-0.64 (p=0.002). Myofibers atrophy wasn't observed. The ATPase analyses of skeletal muscle biopsies from patients and controls showed a higher percentage of fast type fibers in skeletal muscle biopsies from cancer patients compared to controls (56% vs 46%, p=0.06) (Tab. I). Interestingly, the internally nucleated myofibers were predominantly of fast type (Fig.1). Conclusions Patients affected with colorectal cancer display early signs of a subclinical myopathy, characterized by abnormally nucleated and regenerating myofibers, that is inversely associated with the presence of lymph node metastasis. Additional follow-up studies are needed to clarify this association, but our observation could provide new diagnostic biomarker of disease progression in specific subgroup of patients. Table I Histopathological features of rectus abdominis muscle biopsies

Clinical background In diabetic patients, especially if elderly, skin ulcers of the foot are among the most debilitating complications. The main risk factors for the ulcer development are diabetic neuropathy (sensory, autonomic), lower limb ischemia (diabetic arteriopathy), limited mobility and altered plantar pressure. The aim of the study was to evaluate the different sites of the diabetic ulcers with regard to their origin.

Clinical background The increasing aging of the Western population is obviously accomplished by an increasing number of older patients with cancer, including pancreatic cancer. Since surgical resection remains the treatment of choice for pancreatic and periampullary neoplasms, increasing number of elderly patients are being referred for pancreatic resection. Recently, some surgical experiences reported an acceptable morbidity rate and outcome in patients with advanced age. This retrospective study analyzes the effects of age on short-term and long-term outcome in a large series of patients who underwent resection for pancreatic or periampullary disease.

Materials and methods 129 patients who underwent radical surgery for N0 colorectal cancer were selected and grouped into three age classes: 80. A subpopulation of 44 patients with colorectal cancer in stage II was selected from the initial group for a comparison with a control population consisting of 63 patients who underwent radical surgery and adjuvant chemotherapy for neoplasms at the same stage.

Background Patients older than 80 years old were excluded from participation in the large controlled randomized trials that demonstrated the efficacy of carotid endarterectomy (CEA) in preventing stroke in selected symptomatic and asymptomatic patients. Because of limited longevity and perceived increased perioperative risk from CEA, alternative treatment options, such as carotid angioplasty and stenting (CAS) have been suggested as a lower-risk alternatives. Many of the reports evaluating CAS have thus used age older than 80 years as one of the high-risk criteria allowing entry into the studies. We analyzed 30-day stroke and death rates after CEA in patients aged 80 or more with severe symptomatic and asymptomatic carotid disease.