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Background: We identified prognostic factors in a 30-year series of STS treated at a single Institution, using an advanced statistical approach.Methods: From June 1988 to July 2019, 164 patients were referred to Rizzoli Orthopedic Hospital, Bologna, Italy) for STS lung metastasectomy (LMTS). The endpoints were lung metastasis recurrence (LMR) and lung metastasisspecific mortality (LMSM).The analysis included directed acyclic graphs, cubic splines, and a competing risk model in order to minimize bias.Results: The 10- and 15- year LMR cumulative incidence were 0.77 (0.76-0.78) whereas 10- and 15- year freedom from LMSM were 0.60 [0.51-0.70] and 0.56 [0.47-0.67], respectively. The malignant peripheral nerve sheath tumor (MPNST) histotype (SHR 4.12 [2.05-8.27]), a disease-free interval (DFI) up to 68 months (HR from 2 [1.7-2.2] to 1.5 [1.1-1.9]) and a LM size >4 mm (3.1 [2.1-4.4]) predicted LMR.Myxofibrosarcoma (HR 2.52[1.64-3.86]), synovial sarcoma (2.53[1.22-5.23]), adjuvant chemotherapy (2.01 [1.11-3.61]), DFI between 2 months and 20 months (HR from 1.5 [1.1-2.3] to 1.3 [1.1-1.7] and primary tumor size a primary tumor size comprised between 3.6 cm and 10 cm predicted LMSM. A sharp increase in LMSM was observed with a tumor size from >20 cm. Conclusions: Our analysis corrected by potential confounders allowed us to identify specific histotypes and DFI intervals as predictors of both LMR and LMSM. Tumor size adjuvant chemotherapy adversely affected LM-related survival. Our findings need to be confirmed by larger randomized studies.

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We test the hypothesis that a model including clinical and computed tomography (CT) features may allow discrimination between benign and malignant lung nodules in patients with soft-tissue sarcoma (STS). Seventy-one patients with STS undergoing their first lung metastasectomy were examined. The performance of multiple logistic regression models including CT features alone, clinical features alone, and combined features, was tested to evaluate the best model in discriminating malignant from benign nodules. The likelihood of malignancy increased by more than 11, 2, 6 and 7 fold, respectively, when histological synovial sarcoma sub-type was associated with the following CT nodule features: size &ge, 5.6 mm, well defined margins, increased size from baseline CT, and new onset at preoperative CT. Likewise, in the case of grade III primary tumor, the odds ratio (OR) increased by more than 17 times when the diameter of pulmonary nodules (PNs) was &gt, 5.6 mm, more than 13 times with well-defined margins, more than 7 times with PNs increased from baseline CT, and more than 20 times when there were new-onset nodules. Finally, when CT nodule was &ge, 5.6 in size, it had well-defined margins, it increased in size from baseline CT, and when new onset nodules at preoperative CT were concomitant to residual primary tumor R2, the risk of malignancy increased by more than 10, 6, 25 and 28 times, respectively. The combination of clinical and CT features has the highest predictive value for detecting the malignancy of pulmonary nodules in patients with soft tissue sarcoma, allowing early detection of nodule malignancy and treatment options.

Background Diverticular disease is common among the elderly. Its management is complex and offers multiple treatment options. Findings Uncomplicated acute diverticulitis is treated with initial conservative therapy, while cases of recurrence are approached with surgery. Perforated acute diverticulitis (Hinchey I and II) it usually treated with apercutaneous drainage followed by elective colonic resection. Therapeutic failure of percutaneous drainage is an indication for emergency surgery. Acute diverticulitis with peritonitis (Hinchey III and IV) requires emergency surgery. The surgical options are two: one-step or two-step operation. According to the data present in literature one-step operation has a lower mortality and complication rate than the two-step operation approach. Conclusions Acute diverticulitis is a condition that requires surgical management. The timing and the surgical technique depend on the single clinical situation.

Background Diverticular Disease (DD) is a common condition in Italy and in other western countries. There is not much data concerning DD’s impact on budget and activity in hospitals. Methods The aim is to detect the clinical workload and the financial impact of diverticular disease in hospitals. Retrospective observational study of all patients treated for diverticular disease during the period of seven years in AOU Federico II. Analysis of inpatient and outpatient investigations, treatment, hospitalization and financial refunds. Results A total of 738 patients were treated and 840 hospital discharge records were registered. There were a total number of 4101 hospitalization days and 753 outpatient accesses. The investigations generated were 416 endoscopies, 197 abdominal CT scans, 177 abdominal ultrasound scans, 109 X-rays tests. A total of 193 surgical operations were performed. The total cost of this activity was € 1.656.802 or 0.2% of the total budget of the hospital. € 1.346.218, were attributable to the department of general surgery, 0.9% of the department’s budget . Conclusions The limited impact of diverticular disease on the budget and activity of AOU Federico II of Naples is mainly due to the absence of an emergency department.

the CT scan revealed the presence of multiple ipodense formations in the body and tail of pancreas. Neoplastic markers (AFP, CEA, CA 19-9, CA 15-3, CA125, TPS) were negative. During the hospital stay an abdominal MR was performed. The exam revealed in the retrocecal adipose tissue the presence of a fluid-filled formation with a diameter of 35 mm that appeared indissociable from the cecum for the presence of a tissutal connection (Figure 1 A – B). Other cystic lesions (communicating with pancreatic duct) were present in the whole pancreas and in the right kidney. The patient underwent exploratory surgery: at laparotomy a yellowish ovalar formation with a diameter of 6 cm was found arising from the mesentery of ileum with partial adhesion of the appendix. The lesion had a cystic aspect and was fluid-filled. We performed a total excision of the lesion and appendicectomy. Histopathological examination was consistent with the diagnosis of mesenteric lymphangioma. The patient has been followed-up for 6 months and no recurrence occurred.

Background Cholecystectomy, gold standard treatment for gallbladder lithiasis, is closely associated with increased bile reflux into the stomach as amply demonstrated by experimental studies. The high prevalence of gallstones in the population and the consequent widespread use of surgical removal of the gallbladder require an assessment of the relationship between cholecystectomy and gastric mucosal disorders. Morphological evaluations performed on serial pre and post – surgical biopsies have provided new acquisitions about gastric damage induced by bile in the organ. Methods 62 elderly patients with gallstone related disease were recruited in a 30 months period. All patients were subjected to the most appropriate treatment (Laparoscopic cholecystectomy). The subjects had a pre-surgical evaluation with: • dyspeptic symptoms questionnaire, • gastric endoscopy with body, antrum, and fundus random biopsies, • histo-pathological analysis of samples and elaboration of bile reflux index (BRI). The same evaluation was repeated at a 6 months follow-up. Results In our series the duodeno-gastric reflux and the consensual biliary gastritis, assessed histologically with the BRI, was found in 58% of the patients after 6 months from cholecystectomy. The demonstrated bile reflux had no effect on H. pylori’s gastric colonization nor on the induction of gastric precancerous lesions. Conclusions Cholecystectomy, gold standard treatment for gallstone-related diseases, is practiced in a high percentage of patients with this condition. Such procedure, considered by many harmless, was, in our study, associated with a significant risk of developing biliary gastritis after 6 months during the postoperative period.

Background The gastro-esophageal reflux disease (GERD) is one of the most frequent disease of the upper gastro-entheric tract. Surgical treatment is reserved to selected patients, affected by severe forms of disease and/or without compliance to medical therapy. In 95%-60% of the patients submitted to surgical antireflux intervention, a notable improvement of the quality of life is observed. Functional evaluations performed on pre and post – surgical pHmetric and manometric examination have provided new acquisitions about improvements in the restoration of anatomical and functional integrity of the esophagus-gastric antireflux barrier. Methods 45 elderly patients with GERD were recruited in a 27 months period. All patients were subjected to laparoscopic Nissen-Rossetti 360° fundoplication. The subjects had a pre-surgical evaluation with: • 24 hours pHmetry, • esophageal manometry, The same evaluation was repeated 1 month and 6 months after surgical intervention. Results In our series all patients get benefit from surgical treatment, with an improvement of pHmetric and manometric parameters and a regression of complications of GERD such as Barrett's metaplasia. In 8.33% of patients a PPI therapy was necessary, after the surgical intervention, to control symptoms. Conclusions The role of surgery in GERD concerns selected patients. Nissen-Rossetti mini-invasive approach is performed with an acceptable percentage of complications (3%-10%). This technique is associated with a good control of GERD symptoms in a short and middle term and with an improvement of functional parameters, such as pHmetric and manometric.

Summary Post-traumatic diaphragmatic hernias(PDH) are possible complications of blunt and penetrating thoracic or abdominal trauma. These hernias may be diagnosed at the time of the initial trauma, but are sometimes recognized only after several months or years during examinations for their related symptoms. We here present the case of a patient in which diagnosis was obtained only after 7 years from the accident and for which a successful laparoscopic repair of the hernia was performed.

Background Gastro-esophageal reflux disease (GERD) is one of the most frequent diseases of the upper gastro-enteric tract and incidence increases during lifetime [1]. In elderly patients [2] with a good LES basal tone and good peristalsis, evaluated with esophageal manometry, and even with a long exposure time fraction and a correlation between episodes of reflux and symptoms (SAP Symptom Association Probability), evaluated with 24h pHmetry [3], severe and refractory symptoms or intolerance to a conservative treatment, had a good response after a laparoscopic 270° fundoplication (Toupet technique); Toupet’s technique seems to offer good results such as Nissen-Rossetti fundoplication in terms of symptom control in a short-term evaluation [4-7].