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Carlo Boselli,1 Claudio Renzi,2 Alessandro Gemini,1 Elisa Castellani,1 Stefano Trastulli,2 Jacopo Desiderio,2 Alessia Corsi,2 Francesco Barberini,1 Roberto Cirocchi,2 Alberto Santoro,3 Amilcare Parisi,4 Adriano Redler,3 Giuseppe Noya1 1Department of General and Oncologic Surgery, University of Perugia, Perugia, 2Department of General Surgery, University of Perugia, St Maria Hospital, Terni, 3Department of Surgical Sciences, Sapienza University of Rome, Rome, 4Department of Digestive Surgery, St Maria Hospital, Terni, Italy Purpose: In asymptomatic patients with Stage IV colorectal cancer, the debate continues over the efficacy of primary resection compared to chemotherapy alone. The aim of this study was to define the optimal management for asymptomatic patients with colorectal cancer and unresectable liver metastases. Patients and methods: Patients receiving elective surgery (n = 17) were compared to patients receiving chemotherapy only (n = 31). Data concerning patients' demographics, location of primary tumor, comorbidities, performance status, Child–Pugh score, extension of liver metastases, size of primary, and other secondary locations were collected. Results: Thirty-day mortality after chemotherapy was lower than that after surgical resection (19.3% versus 29.4%; not significant). In patients with >75% hepatic involvement, mortality at 1 month was higher after receiving surgical treatment than after chemotherapy alone (50% versus 25%). In patients with

Breast surgery is classified among the procedures performed in clean surgery and is associated with a low incidence of wound infection (3-15%). The objective of this study was to evaluate the advantages antibiotic prophylaxis in patients undergoing breast surgery. A multicenter randomized controlled study was performed between January 2008 and November 2008. One thousand four hundred patients were enrolled in prospective randomized study; surgical wound infection was found in 41 patients (2.93%). In our RCT we have shown that in breast surgery antibiotic prophylaxis does not present significant advantages in patients with potential risk of infection (17 patients, 2.42%, subjected to antibiotic prophylaxis vs 24 patients, 3.43%, without antibiotic prophylaxis) (P = 0.27). In patients with drainage there is a significant minor incidence of wound infections in patients receiving antibiotic prophylaxis (5 patients, 0.92%, subjected to antibiotic prophylaxis vs 14 patients, 3.09%, without antibiotic prophylaxis) (P = 0.02). CONCLUSION: This study is only a preliminary RCT to be followed by a study which should be enrolled more patients in order to get the results as statistically significant.

Solid-phase microextraction has been applied for the first time to the determination of trace concentrations of some brominated flame-retardant compounds (BFRs) in water samples. For the development of the method, six polybrominated diphenyl ethers and two polybrominated biphenyls were considered as target analytes. The factors expected to influence the extraction process are fully discussed. Quantification has been performed by gas chromatography/tandem mass spectrometry using an ion trap mass analyzer. This is also the first time that tandem mass spectrometry is applied with these analytes. Unlike conventional methods for BFR analysis, which involve solvent extraction and several cleanup steps before gas chromatography, the proposed method uses headspace extraction and hard contamination of the chromatographic system is prevented. In addition, tandem mass spectrometry provides selectivity and sensitivity in the detection process. The method performs well achieving good linearity (R(2)0.997), precision, and detection limits (S/N = 3) ranging from 7.5 to 190 pg/L. The method has been applied to a variety of water samples.

To describe three cases of solitary cecal diverticulum, and trying to evaluate the better method of diagnosis and treatment with analysis of the literature.Description of three cases of solitary cecal diverticulum's perforation admitted in the Department of General and Oncologic Surgery, Santa Maria della Misericordia Hospital, Perugia, during the period January 2011 - January 2012.In all patients the clinical presentation was very similar to that of acute appendicitis. Preoperative diagnosis was achieved in one case through abdominal CT scan, other two cases were identified at final pathology. At one year from the treatment all patient are still alive.Cecal diverticulum is a rare condition, often diagnosed either casually or because of inflammatory or perforative complications. The highest incidence is found in Western population. Because of the clinical presentation, very similar to the appendicitis, and the inflammatory reaction involving the colon and its surrounding tissues, the pre- and intra-operative diagnosis are very difficult. The diagnosis is almost always histological. The treatment may vary from simple expectant medical management, carried out with bowel rest, parenteral support and antibiotics as for left-sided diverticulitis, to surgical approach, performed through simple diverticulectomy or by classical right hemicolectomy.Pre-surgical and, also intra-operative, diagnosis of perforated solitary cecal diverticulum is clearly difficult. CT scan represents the gold standard for the differential diagnosis. Right hemicolectomy is an effective and safe approach, allowing accurate control, preventing complications and recurrences, and it represents the optimal management of the disease.

Despite centuries of anatomical studies, controversies and contradictions still exist in the literature regarding the definition, anatomical terminology and the limits of the abdominal wall. We conducted a systematic research of books published from 1901 until December 2012 in Google Books. After the index screening, 16 remaining books were further assessed for eligibility. We decided to exclude journals. The aim of the study was to focus on surface landmarks and borders of the abdominal cavity. After this revision of the literature, we propose that the surface landmarks of the abdominal wall should be standardized. © 2014 Termedia and Banach.

Patients undergoing mastectomy for breast cancer have to face a long and elaborated therapeutic path, very often burdened by reoperation to replace the temporary expander, used to enlarge the submuscular pouch, with a definitive implant. Postoperative planning represents a critical moment of care, as it requires the integration of multiple treatments (chemotherapy, radiotherapy, hormonotherapy) each with a specific deadline. We believe that in such a complex multidisciplinary approach, coordination among the different therapeutic phases should be the key to success. The aim of the Breast Unit is to manage rapidly the ad hoc paths set out for each patient in order to guarantee compliance with adequate therapeutic timing. With this purpose in mind we tested the advantage of immediate reconstruction with definitive implants, by using a polypropylene mesh which, prolonging the inferolateral profile of the pectoralis major muscle (PMM), allows for direct accommodation of the desired implant volume. This leads to a single-step surgical approach, guaranteeing at the same time reduced interference with adjuvant therapies and good aesthetic results. We applied this technique to 4 patients, one of which was bilateral and, in spite of the restricted number of cases, our results seem to be promising.

Nipple sparing mastectomy (NSM) is the current surgical alternative to conventional techniques, when mastectomy is required. This less invasive procedure safeguards the integrity of the nipple areola complex (NAC), whose removal is recognized as a factor that exacerbates the patient's feeling of mutilation, however ensuring oncological radicality for women with breast cancer.From January 2003 to January 2011, 77 patients underwent Nipple Sparing Mastectomy (NSM). Patients were carefully selected according to specific criteria. When requested, postoperative radiotherapy on the residual glandular tissue was performed within 6 months of surgery. Patients were on close clinical and instrumental follow-up every 4 months for 2 years and every 6 months for the remaining 3 years.Of the 77 patients who underwent NSM, 10 suffering from bilateral cancer were subjected to bilateral procedure, for a total of 87 performed procedures. Furthermore, in the same group, 13 NSMs were carried out for preventive purposes. The average diameter of resected tumors was 13.5 mm, with a range of 2 to 25 mm. During the follow-up (range 23-115 months, mean 50.33 months) 2 locoregional recurrences in the NAC were observed, identified through instrumental check, and surgically treated by NAC removal after 33 and 37 months respectively.According to the litterature data and confirmed by our experience, we consider NSM as an oncologically safe technique that, in the respect of inclusion criteria may be performed in any patient with indication to mastectomy. A careful selection of patients by a multidisciplinary team according to strict criteria is the key in determining feasibility as well as oncological safety and should lead the general acceptance and widespread use of such surgical technique.

396-402 borgesr@ula.ve

Appendiceal mucocele is a rare disease (0.3% of all appendectomy) and is characterized by the accumulation of mucoid material in the appendiceal lumen. Etiopathogenesis can be inflammatory or neoplastic. Four entities can be distinguished on the basis of histopathologic epithelial characteristics: simple appendiceal mucocele (AM), mucocele with epithelial hyperplasia, cystadenoma and cystadenocarcinoma; the last two subgroups represent neoplastic forms. Dissemination of neoplastic cells and mucoid material in abdominal cavity, caused by appendiceal perforation, clinically results in pseudomyxoma peritonei which is the dramatic evolution in 10-15% of cases. Clinically it can remain either asymptomatic for long time or it can manifest with abdominal pain that can be associated with the presence of a palpable mass. The most common clinical manifestation is pain in the right iliac fossa. Preoperative diagnosis is rare, while it is more frequently intraoperative. Therapy is fundamentally surgical: appendectomy is curative for simple AM, for AM with epithelial hyperplasia and for cystadenoma with intact appendiceal base; cecum resection is indicated for cystadenoma with larger base of implantation; right hemicolectomy has been the elective treatment in case of cystadenocarcinoma for several years although Gonzalez-Moreno and Sugarbaker have recently demonstrated its validity as definitive treatment only if it is performed in order to obtain complete cytoreduction, if there is lymph node involvement, or if histopathological examination indicates non-mucinous type. We report the case of a 60-year-old woman that presented with cystic neoformation in the right iliac fossa, that was preoperatively considered deriving from the ovary. We intraoperatively found the presence of appendiceal mucocele that histological examination defined as mucinous cystadenoma.

the Abdominal Compartment Syndrome (ACS) is an increasingly recognized complication of both medical and surgical patients. The World Society of the Abdominal Compartmental Syndrome defined Intra Abdominal Hypertension (IAH) as a mean Intra Abdominal Pressure (IAP) ≥ 12 mm Hg and the ACS as IAP ≥ 20 mmHg (with or without an abdominal perfusion pressure60 mm Hg) that is associated with dysfunction or failure of one or more organ systems that was not previously present. The IAH contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of ACS.This study aims to investigate the clinical significance of IAH, the prevalence of ACS and the importance to the effects to the abdominal decompressive re-laparotomy. Patients and methods. The study included 10 patients, 4 men and 6 women with an average age of 68 years (range, 38-86) operated and and treated with xifo-pubic laparotomy between January 2007 and December 2008. According to gold-standard methods, we measured the IAP by indirect measurement using the transvescical route via Foley bladder catheter.among 10 patients with laparotomy, 8 patients (80%) developed IAH20 mm Hg but they have not reported significant organ dysfunction , while 2 patients (20%) developed an IAH20 mm Hg associated whit organ dysfunction. For this reason, the last 2 patients were undergoing to the decompressive re-laparotomy with temporary closure.in according to our experience and the results of the literature, we believe essential monitoring abdominal pressure in patients with abdominal laparotomy. The abdominal decompressive re-laparotomy is a useful procedure to reduce symptoms and improve the health of the patient.

Bij duurzaam ondernemen in de glastuinbouw staat allereerst het veiligstellen van de continuïteit van de onderneming centraal. Vertrekpunt hierbij is dat het realiseren van profit op termijn niet mogelijk is zonder rekening te houden met people en planet

Nipple-sparing mastectomy (NSM) combines a skin-sparing mastectomy with preservation of the Nipple Areola Complex (NAC), intraoperative pathological assessment of the nipple tissue core, and immediate reconstruction, thereby permitting better cosmesis for patients undergoing total mastectomy. Radiotherapy of the NAC was carried out in every single patient after surgery. The procedure was first performed on selected patients following a clinical research protocol. From January 2003 to June 2004, 10 patients underwent nipple sparing mastectomy followed by reconstruction (4 of them decided also to undergo a prophylactic mastectomy on the other breast) at the Breast Unit, Policlinico Monteluce, Perugia, Italy. Patients had been accurately selected before the operation following some criteria previously assessed by a team of specialists including the breast surgeon, the oncological physician, the radiotherapist and the plastic surgeon. Histology of the 10 NSMs confirmed invasive carcinoma in 3 cases and in situ carcinoma in the remainder. Superficial necrosis of the NAC that settled down spontaneously without consequences occurred in 2 cases; loss of sensitivity of the NAC in 4 patients; 1 patient developed haematoma. No asymmetry was reported. All women were clear of cancer after the treatment. Nipple-sparing mastectomy is the procedure of choice on selected patients.

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.

A phase III malaria vaccine trial in 13 villages in an endemic area, South Venezuela, compared incidence rates of Plasmodium falciparum and Plasmodium vivax infections in 1422 vaccinated and 938 nonvaccinated subjects over 18 months. The SPf66 vaccine was given in three doses, on days 0, 20, and 112. Vaccination was complete in 976 subjects (68.7%). Minor side effects requiring no treatment were reported by 123 (12.6%), with an apparent increase in frequency from the first to the third vaccine dose. No autoimmune evidence was observed in a sample of subjects. Antibodies against SPf66 were present at low titers in 24.7% of tested subjects before vaccination, increasing to 53.6% after the second dose and to 73.6% after the third dose; 26.4% of subjects initially seronegative never seroconverted. The SPf66 malaria vaccine showed a protective efficacy of 55% (95% confidence interval, 21%-75%) against P. falciparum and of 41% (19%-57%) against P. vivax malaria.

This retrospective study analyses the value of endoscopic polypectomy as the operation of choice in cases of early invasive colorectal carcinoma located on the adenomatous polyp. Under these conditions the authors outline their therapeutic strategy, based not only on the histological characteristics of lesions, but also on the evaluation of the risk/benefit ratio established in relation to the characteristics of each individual patient.

The authors analyse their experience of 30 cases of which 25 underwent surgery. In addition to the onset of complications, indications for surgery were based on the presence of severe painful symptoms which did not respond to medical treatment. Over the past few years the latter have represented one of the main indications with a success rate of between 80-90% of cases. The type of surgery must be personalized to the characteristics of each individual patient on the basis of morphological alterations of the gland, which are easily defined during a preoperative study using CPRE, ultrasonography and CT. Of these, CPRE has been found to be the most reliable in diagnostic terms, since it can detect structural alterations at a relatively early phase and is of considerable value in differential diagnosis, which is at times extremely difficult, with pancreatic carcinoma.