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Background: A remarkable number of patients presents with multiple primary malignancies (MPM) over their lifetimes. In most cases inherited syndromes, iatrogenic, or viral factors are implicated, while in some cases it is not possible to ascertain a clear aetiopathogenesis., Methods: Starting from a series of 315 patients with MPM, we focused our attention on those with extremely infrequent combinations of tumours. We retrospectively analysed patients' characteristics, type of first and second tumour and the interval between the two tumours. We made a comparison between our own data and data from surveillance, epidemiology, and end results cancer registries, the largest global series on this topic., Results: Six patients presented with unusual associations, namely, central nervous system (CNS)/colon, testis/stomach, colon/CNS, CNS/kidney, uterus/soft tissue, and bone/breast. The median age was 50.5 years at the diagnosis of second neoplasm and the male:female ratio was 1:1. All six patients underwent surgery for both tumours. The median interval between the first and the second tumour was 11.3 years (range 1-36 years). Five patients were given chemotherapy as adjuvant systemic treatment, and two of them with CNS tumours also received radiotherapy., Discussion: We analysed the behaviour of these rare tumours as first and second neoplasms. More frequent combinations and possible aetiological factors were evaluated., Conclusions: Follow-up for patients recovering from a first tumour must be strict, as there is the risk of developing MPM, even after a long time period. Advancement in biomolecular knowledge and cooperation among different specialists are strongly needed to reduce mortality related to MPM and to foresee their occurrence.

Introduction: Laparoscopic cholecystectomy (LC) is a well standardized technique. There are two main approaches, proposed by French and American Schools. They have similar operative times, but different arrangements for site ports insertions and for patients and operators' position at operative bed. Although we can foresee new scenarios for the next future (robotics, SILS, NOTES, minilaparoscopy), it seemed interesting to describe a simple variation to LC introduced in the last years in our experience relative to the positioning of operators and patient during standard American technique., Methods: In a retrospective analysis of 140 patients operated on for LC in the last two years (70 with French technique and 70 with "American modified" technique) we compared the following parameters: laparotomic conversion, duration of operation, hospital stay, morbidity and mortality rates., Results: Conversion to laparotomy, length of operative time and hospital stay were similar. Morbidity rates were slightly different, but it did not show statistically significant differences between the two groups. Mortality was nil., Considerations: Our variant to LC seems to be almost a compromise between the two main techniques. Our operators' arrangement gave a greater comfort for surgeons during LC and our results were similar to those reported with adoption of French and American approaches. These considerations led us to judge our variation safe and reliable.

Aim: The use of synthetic mesh in transplant patients is still under debate. In this paper the authors report their preliminary experience on biological prosthesis for surgical treatment of incisional hernias in transplant patients., Material of Study: Between 2009-2010, 10 patients with incisional hernia underwent surgery using a biological prosthesis (porcine dermis collagen). All patients were transplanted: 9 kidney transplants and 1 liver transplant., Results: In all patients postoperative course was uneventful and were not observed complications related to surgery, kind of prosthesis or transplanted organs. At follow up, laparoplasty was associated with good functional outcome., Discussion: Transplant patients are at risk for use of synthetic prostheses, as immunosuppressed. In our preliminary experience biological prostheses compared to synthetic ones showed a greater ability to integrate into tissues, to resist bacterial colonization and to reduce cytotoxic or allergenic reactions, providing similar functional results. Moreover it must be added that biological prostheses did not require reductions/suspensions of immunosuppressive therapy and resulted to be versatile. All these features are particularly sought in incisional hernias surgery of transplanted patients., Conclusions: Surgery of incisional hernias in transplanted patients requires a prosthesis with characteristics as close as possible to the ideal one and, in this sense, biological prostheses would seem to outweigh synthetic ones. In our experience, biological prostheses have shown to be safe, effective and reliable; therefore they seem to be able to open new horizons in the treatment of wall defects in this group of patients.

Aim: Pseudoaneurysm (PA) at the anastomosis site in kidney transplantation is a rare but serious complication that usually requires graft nephrectomy. Literature reports are sporadic and usually focused on limb rather than graft salvage. In this paper we focus on this last point., Material of Study: 6 patients presenting large PA at the anastomosis between iliac and graft artery were identified in our series. The diagnosis was performed with US, AngioTC scan and angiography. Blood cultures and labeled leukocyte scintigraphy were also performed. All patients underwent open surgery., Results: Transplant nephrectomy was needed in all cases except one, in which it was possible to perform a graft replanting on hypogastric artery. Our perioperative mortality and morbidity rate was recorded., Discussion: Etiology of PA is multifactorial, however an association with chronic rejection or infection must be also considered. Our mortality and morbidity rates are in accordance to literature. In our experience we observed only large PA so to require an open surgery but this approach has allowed the rescue of graft functioning just in a single case. Endovascular procedures are linked to higher rate of graft salvage than surgery but they can be used just in selected cases., Conclusions: Our experience and literature review led us to believe that the rate of graft salvage in patients with large PA at anastomosis site could be improved only by a planned therapeutic program that includes surgical and endovascular approach, taking the advantages of both technique and overcoming their limits.

Introduction: Crohn's Disease (CD) occurs in the elderly in 5 - 25% of cases. Aim of our study: to define the features of clinical presentation, diagnostic tools and therapy of CD in old age., Methods: In the last ten years we observed in our Department 47 patients affected by CD. We divided them into two groups: A (42 patients < 65 years old) and B (5 patients ≥ 65 years old). A retrospective survey evaluated the clinical presentation, diagnosis and treatments with relative outcomes., Results: Group A: 23/42 patients (54,76%) were operated on. The most important indication for surgery was intestinal obstruction (15/42 pts, 65,2%). Small bowel resection was the most frequent surgical procedure (13/42 pts, 56,2%). Overall, 2/23 (8,7%) of the patients developed postoperative complications. There was no postoperative mortality. 8 pts (34,7 %) developed recrudescence of CD. Group B: 3 of 5 pts were operated on. Intestinal obstruction was the indication for surgery in all cases (100%). Two patients underwent small bowel resection (66,6%) and the third patient was submitted to an ileo-colic resection (33,3%). There was no mortality in the aftermath of surgery. In 2/3 operated patients (66,6%) recurrence occurred. All operations in the old patients were performed in urgency., Conclusions: Surgery of CD in the elderly appears in our experience to have the same indications and procedures as in young patients. The postoperative morbidity, mortality and recurrence rates are similar in two groups even if we observed slightly higher postoperative morbidity rates in elderly due to the presence of comorbidity.

Introduction: Gastric or intestinal foreign bodies may cause heterogeneous symptoms ranging from asymptomatic conditions to chronic pain and, in some cases, occlusion and/or perforation. There are sporadic reports of intraluminal migration of medical devices. Most commonly they are sponges, hernia meshes, gastrotomy tubes, while surgical drains are very rarely reported., Methods: A 79 year-old female who consulted our department in May 2009 for abdominal pain and constipation. Her symptomatology started in 2006 some months after an anterior resection for sigmoid diverticulitis associated to obstructed incisional hernia. The symptoms had begun a few months after the operation and were progressively increased month by month. An abdominal CT- scan showed the presence of an intra-peritoneal foreign body and at laparotomy a drain fragment was found inside a small bowel loop and pulled out through a small enterotomy., Results: Post-operative course was regular and the patient was discharged at 7th day., Discussion: The observation of this case and a literature review led us to analyze the origin and the clinical problems of this very rare complication. Incidence, symptomatology, diagnosis and treatment were analysed., Conclusions: The intraluminal migration of a surgical drain is very rare. The diagnosis is easy by abdominal plan radiogram or CT-scan, but it is casually achieved, because, as it almost always occurs in case of intra-peritoneal foreign bodies, the clinical suspicion is focused on other conditions that most frequently cause abdominal symptoms. When a foreign body is found in intraluminal position and its endoscopic removal is not feasible, then surgery is mandatory and resolutive.

AIM: The purpose of this study is to analyze a "rare" complication on the management of abdominal surgical drains: abdominal drainage's retention. Starting from our experience we reviewed literature on this topic MATERIAL OF STUDY: We report two cases (occurred on 2004 and 2010) of retained intraperitoneal drain occurred in the immediate postoperative period after laparoscopic cholecystectomy. RESULTS: Both patients were successfully treated by early laparoscopic removal. DISCUSSION: We compared our experience with literature. Incidence, ethiology, prevention, diagnosis and treatment of this rare complication are analysed. We also considered the guidelines in the placement of intraperitoneal drains, the different fixation techniques, the causes of fragmentation of the drainage and removal techniques. CONCLUSIONS: Retained intraperitoneal drain secondary to fracture and adhesion in the immediate postoperative period is rare but probably underestimated surgical complication. It is impossible to know its real incidence. The role of laparoscopy is emphasized because this approach is cosmetically acceptable, contributes to early recovery and discharge of the patient, and helps to lessen the friction in worsening doctor-patient relationship. KEY WORDS: Abdominal drainage, Drain-related complications, Laparoscopy, Retained intraperitoneal drain.

Gastric carcinoma is the second most common cause of digestive tumour-related death in Europe, North America and Asia. Today, the gold standard of treatment is still surgery, but outcomes to date are unsatisfactory. The Japanese Society for Research in Gastric Cancer (JSRGC) recommends the routine execution of splenectomy during gastrectomy. This recommendation is contested by western Authors because of increased morbidity and mortality without any real advantage in terms of survival. Patients treated for gastric cancer in our department between 1993 and 2002 were selected for this study. The 132 patients recruited were divided into two groups: a) those treated for gastric cancer without splenectomy; and b) those in whom splenectomy was performed in conjunction with gastrectomy. We analysed: the extent of lymph node dissection, the execution of the splenectomy, and the prognostic importance of factors relating to the patient, tumour and surgeon. Splenectomy was not associated with any increase in morbidity. Complications, especially of the septic type, and perioperative mortality were similar in both groups, and the same was true of survival at both 3 and 5 years. In our opinion, splenectomy should not be routinely combined with surgery for gastric cancer but could be considered for T3-T4 neoplasms or those localized in the upper two thirds of the stomach.