Predictive Factors of Recurrence After Laparoscopic Incisional Hernia Repair: A Retrospective Multicentre Cohort Study

Background: The main purpose of this study was to analyze patient-related factors that may influence the risk of hernia recurrence following laparoscopic incisional hernia repair (LIHR), including the potential role of chosen materials. Materials and Methods: A multicenter, retrospective cohort study was conducted on all patients who were aged >18 years and who underwent elective laparoscopic incisional hernia mesh repair at the Departments of Surgery of the S. Anna University Hospital in Ferrara and Sassuolo Hospital in Modena, Italy. Exclusion criteria were as follows: patients undergoing an open or emergency incisional hernia repair or with primary ventral hernia. All hernia and operative variables that may favor hernia recurrence were collected and analyzed. Follow-up was conducted through a standardized telephone interview, followed by an outpatient visit and diagnostic imaging if needed. Results: From September 2002 to September 2017, 312 consecutive patients underwent elective laparoscopic incisional hernia mesh repair. At a mean 22-month follow-up, 273 patients presented no recurrence of incisional hernia and 39 had relapsed. Intra- and postoperative complications were similar between groups. Unadjusted Cox regression analysis showed a statistically significant association between both the partially absorbable mesh (P < .0001) and absorbable tacks (P = .001) and recurrence, while after adjusting for potential confounders, only the partially absorbable mesh was significantly associated with recurrence (P = .007). Conclusions: The laparoscopic approach may be considered safe for incisional hernia mesh repair. In this multicenter, retrospective cohort study, the use of a partially absorbable mesh in LIHR was the only predictor of hernia recurrence. The partially absorbable mesh that was investigated, however, has been withdrawn from the market.

Mesh-tissue integration of synthetic and biologic meshes in wall surgery: brief state of art

Many studies show that surgical hernia repair with the use of prosthetic meshes can result in pain, hernia recurrence, contraction and mesh rupture. Numerous experimental studies have been conducted to understand the effect of mesh stiffness, pore size and mesh patterns on mesh biocompatibility. The purpose of this mini review is to present an overview of the contracture, adhesion, tissue regrowth and histological response characteristics of permanent and absorbable mesh. Indeed, the mechanics of mesh-human tissue interaction is poorly understood in the literature. It has been shown that early integration of biological meshes is critical for sustained hernia repair. One of the emerging experimental approaches is to combine cell-based regenerative medicine with mesh materials. Studies in preclinical models show that the use of synthetic and biological meshes with autologous cell implantation improves the biocompatibility of biomaterials, promoting key tissue regeneration processes such as adhesion and vascularisation.

Tissue reconstruction of abdominal wall with butyric acid-based nets: preliminary in vitro test using tissue engineering strategies

OBJECTIVE

A hernia of the abdominal wall is an opening of the muscles in the abdominal wall, which is frequently treated via the application of a surgical mesh. The purpose of this research is to study how human adipose-derived stem cells (hADSCs) interact with Phasix™ Mesh, a commercially available mesh for hernia repair. Studying how cells derived from the abdominal region behave with Phasix™ Mesh is crucial to improve the state of the art of current surgery and achieve effective tissue restoration.

MATERIALS AND METHODS

hADSCs were seeded onto Phasix™ Mesh, a fully resorbable surgical mesh of poly (4-hydroxybutyric acid) (P4HB). Cell viability was assessed through MTT assay, and cell growth and adhesion were evaluated via multiple imaging techniques and gene imaging profiling.

RESULTS

Results confirm that the nets support cells proliferation, extracellular matrix production and increasing of angiogenetic factor.

CONCLUSIONS

Butyric acid-based nets are promising scaffolds for abdominal wall reconstruction.

Non-traumatic emergency abdominal surgery in nonagenarian patients: a retrospective study

PURPOSE

The primary aim of this study was to evaluate the 30-day survival of nonagenarian patients who underwent non-traumatic emergency abdominal surgery. Other aims were: 90-day and 12-month survival rates, the postoperative complications rate, the impact of the emergency operation on postoperative functional status, the accuracy of the P-POSSUM in predicting 30-day postoperative mortality and changes in care services after surgery.

METHODS

This was a retrospective cohort study of nonagenarian patients who underwent non-traumatic emergency abdominal surgery between January 2010 and June 2017. Patients were divided in two groups according to the 30-day survival status to compare the distribution of patients' characteristics and postoperative outcomes. Overall survival was estimated using the Kaplan-Meier method. To assess the accuracy of P-POSSUM to predict 30-day mortality, a receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit test were used.

RESULTS

85 nonagenarian patients were enrolled in this study; of these, 27 (31.8%) died within 30 days. The Kaplan-Meier curve showed a rapid decline in survival over the first 30 postoperative days, followed by a more gradual reduction during the rest of the first year. The majority of patients (92.6%) who died within 30 days experienced a medical complication, with a preponderance of respiratory failure (48.2%) and multiple organ failure (33.3%). In the surviving patients, the postoperative functional status had worsened, and 64.2% of patients did not return to their original housing situation or were institutionalized. The accuracy of P-POSSUM in predicting 30-day mortality in nonagenarian patients was poor.

CONCLUSIONS

This study may help doctors convey the postoperative risks of morbidity and mortality, and also to adequately inform relatives about the possible adverse discharge destination of surviving nonagenarian patients with a consequent increase in care needs.

Clinical outcomes and quality of life associated with the use of a biosynthetic mesh for complex ventral hernia repair: analysis of the "Italian Hernia Club" registry

With the development of newer meshes and approaches to hernia repair, it is currently difficult to evaluate their performances while considering the patients' perspective. The aim of the study was to assess the clinical outcomes and quality of life consequences of abdominal hernia repairs performed in Italy using Phasix and Phasix ST meshes through the analysis of real-world data to support the choice of new generation biosynthetic meshes. An observational, prospective, multicentre study was conducted in 10 Italian clinical centres from May 2015 to February 2018 and in 15 Italian clinical centres from March 2018 to May 2019. The evaluation focused on patients with VHWG grade II-III who underwent primary ventral hernia repair or incisional hernia intervention with a follow-up of at least 18 months. Primary endpoints included complications' rates, and secondary outcomes focused on patient quality of life as measured by the EuroQol questionnaire. Seventy-five patients were analysed. The main complications were: 1.3% infected mesh removal, 4.0% superficial infection requiring procedural intervention, 0% deep/organ infection, 8.0% recurrence, 5.3% reintervention, and 6.7% drained seroma. The mean quality of life utility values ranged from 0.768 (baseline) to 0.967 (36 months). To date, Phasix meshes have proven to be suitable prostheses in preventing recurrence, with promising outcomes in terms of early and late complications and in improving patient quality of life.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Prognostic and Therapeutic Impact of Sentinel Node Micrometastasis in Patients with Invasive Breast Cancer

Aims and Background

Locoregional lymph node status is one of the most important prognostic factors determining the need for adjuvant chemotherapy in patients with breast cancer. Many authors have reported that micrometastases were not detected by routine sectioning of lymph nodes but were identified by multiple sectioning and additional staining. Among lymph node-negative patients 15-20% had an unfavorable outcome at five years from primary surgery. Sentinel lymph node (SLN) biopsy is an accurate technique for identifying axillary metastases because the pathologist utilizes hematoxylin-eosin (H-E) staining together with immunohistochemistry (IH) to examine all lymph node sections. Sentinel node micrometastasis has therefore become an important tumor-related prognostic factor.

Methods and Study Design

From November 1997 to October 2001 we examined in 210 patients the pathological features of primary breast lesions and SLN metastases and we correlated these with the tumor status of non-SLNs in the same axillary basin. We applied IH examination to both SLNs and non-SLNs of patients who were negative for metastasis by standard H-E examination.

Results

In this study lymph node staging was based on SLN findings, primary tumor size, and the presence of peritumoral lymphovascular invasion (LVI). We found 18 SLN micrometastases (9%) in 210 patients and one of these (5.5% of patients with SLN micrometastasis) also had one non-SLN metastasis: this patient had LVI and a larger primary tumor than patients with SLN micrometastasis without non-SLN metastasis. We also found 24 SLN macrometastases (11.5%) in 210 patients and 13 of these (54.2% of patients with SLN macrometastases) had one or more non-SLN metastases.

Conclusions

According to the results reported in the literature, tumor cells are unlikely to be found in non-SLNs when the primary lesion is small and SLN involvement micrometastatic (5.5% in our experience, 7% in Giuliano's). Our findings suggest that axillary lymph node dissection may not be necessary in patients with SLN micrometastasis from T1 lesions.

Reliability and Accuracy of Sentinel Node Biopsy in Cutaneous Malignant Melanoma

Aims and Background

The aims of this study were 1) to investigate whether sentinel lymph node (SLN) biopsy could become the method of choice for the early detection of metastatic disease in patients with malignant melanoma and 2) to identify those patients with lymph node metastases who could benefit from regional lymphadenectomy.

Methods and Study Design

Our study started in March 1998 and involved 110 patients with primary cutaneous malignant melanoma stage I or II (AJCC) in whom the primary lesion had been surgically removed no more than 90 days previously. On the day of lymph node dissection patients were given an intradermal injection of colloid particles of human serum albumin labeled with technetium-99m and an injection of isosulfan blue. The surgical procedure was usually performed with local anesthesia but in some cases locoregional or general anesthesia was preferred. Contralateral and ipsilateral lymphatic areas were scanned with a hand-held gamma camera (Scintiprobe MR 100) to measure the background and identify the hot point indicating the location of the sentinel node to direct the incision.

Results

The combined use of lymphoscintigraphy, isosulfan blue and gamma probe allowed us to identify sentinel nodes in 108 of 110 patients (98.18%) while the SLN was blue in only 90 cases (81.81%). The SLN was positive for metastases in 13 of the 108 patients (12.03%) and regional and distal lymphadenectomy was performed in all of them. The distribution of positive SLNs by primary lesion thickness was as follows: 0.76-1.5 mm: one positive SLN/44 patients (2.27%); 1.51-4 mm: six positive SLNs/51 patients (11.7%); >4 mm: six positive SLNs/15 patients (40%). Only four of 12 patients with ulcerated cutaneous melanoma had positive SLNs. The patients in our study underwent follow-up visits every four months. The median follow-up was 481 days (range, 97-1271 days).

Conclusions

In patients with primary cutaneous melanoma the histological status of the SLN accurately reflects the presence or absence of metastatic disease in the relevant regional lymph node basin. Complete lymph node dissection should only be performed in patients with positive SLNs. Patients with lesions >4 mm are likely to develop recurrences and to die of systemic disease, so in these patients the usefulness of SLN biopsy is questionable. In conclusion, sentinel node mapping is a rational approach for the selection of patients who might benefit from early lymph node dissection of the affected basin.

Sentinel Node Biopsy in the Evaluation of the Internal Mammary Node Chain in Patients with Breast Cancer

Aims and Background

In patients with breast cancer the presence of internal mammary chain (IMC) metastases changes tumor staging, and the occurrence of IMC drainage is quite common in breast cancer. Nevertheless, IMC dissection is not a routine procedure in modern surgical approaches towards breast cancer. We therefore need minimally invasive techniques for accurate assessment of the IMC nodal basin. The aim of this study was to investigate whether sentinel node biopsy (SLNB) could offer a solution.

Methods and Study Design

From November 1997 to June 2001 143 female patients who were eligible for breast cancer surgery were included in the study. All patients had T1 breast cancer and clinically negative axillae. Patients were submitted to preoperative lymphoscintigraphy with subsequent SLNB. We used a 99m-technetium nanocolloid tracer (Nanocoll®) that was injected peritumorally so as to have about 10 MBq of radioactivity at the time of surgery. Scintigraphy was performed about 17 hours after tracer administration. During surgery, lymphoscintigraphic imaging and a gamma ray detection probe were used to locate the sentinel node. Histological examination after embedding in paraffin was usually requested and multilevel sectioning of the sentinel node (SLN) was performed, with hematoxylin and eosin staining and immunohistochemistry.

Results

Preoperative lymphoscintigraphy localized SLNs in the IMC basin in 27 of 143 patients (18.9%). Harvesting of IMC-SLNs based on lymphoscintigraphy results was successful in 20 of 27 patients (74.1 %). Histological examination revealed micrometastases in four of the 20 harvested nodes. One of these patients showed no axillary drainage and no axillary lymph node dissection was therefore performed. In the remaining three patients also axillary SLNs were harvested, which turned out be free from metastatic involvement.

Conclusions

In our experience lymphoscintigraphy with SLNB was an accurate method to detect IMC metastases in patients with breast cancer. We recommend peritumoral tracer injection and a reasonable interval between injection and scintigraphy. IMC-SLN biopsy did not result in any serious additional complications or morbidity. In our study this approach led to improved cancer staging: four of 20 harvested IMC-SLNs proved to be micrometastatic. None of these four patients had metastatic axillary SLNs. Exclusive drainage to the IMC is present in only a small number of breast cancer patients, and our results suggest that it is possible to avoid unnecessary axillary node dissection in such cases.

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients

PURPOSE

To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS).

METHODS

Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014.

RESULTS

Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3-4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS.

CONCLUSIONS

Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients' characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients

BACKGROUND

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.

THE AIMS OF OUR STUDY WERE

(1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.

METHODS

This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.

RESULTS

The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).

CONCLUSIONS

Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Primary anorectal melanoma: an update

The anorectum is a rare anatomic location for primary melanoma. Mucosal melanoma is a distinct biological and clinical entity from the more common cutaneous melanoma. It portrays worse prognosis than cutaneous melanoma, with distant metastases being the overwhelming cause of morbidity and mortality. Surgery is the treatment of choice, but significant controversy exists over the extent of surgical resection. We present an update on the state of the art of anorectal mucosal melanoma. To illustrate the multimodality approach to anorectal melanoma, we present a typical patient.

Clinical and Therapeutic Importance of Sentinel Node Biopsy of the Internal Mammary Chain in Patients with Breast Cancer: A Single-Center Study with Long-Term Follow-Up

BACKGROUND

We evaluated the incidence of sentinel lymph nodes (SLNs) in the internal mammary chain, calculated the lymphoscintigraphy and surgical detection rates, and evaluated the clinical effect on staging and the therapeutic approach in patients with breast cancer.

METHODS

The study involved 741 women diagnosed with breast cancer eligible for the SLN technique. Lymphoscintigraphy was performed on the day before the operation by peritumoral injection of (99m)Tc-labeled nanocolloid. During the operation, a gamma probe was used to detect the SLN, which was then removed.

RESULTS

A total of 719 SLNs were found in the axillary chain and 72 in the internal mammary chain. Preoperative lymphoscintigraphy showed 107 hot spots in the internal mammary chain, but only 72 SLNs in 65 patients were identified by the gamma probe and then removed with no complications. Of these 65 patients, 10 had a positive internal mammary chain SLN on final pathologic examination, whereas 55 patients had >or=1 negative SLNs on final pathologic analysis. Thirty-five (53%) of 65 patients had also an axillary SLN, but only 5 patients (8%) had a positive SLN on pathologic analysis.

CONCLUSIONS

Evaluation of the SLNs in the internal mammary chain may provide more accurate staging in breast cancer patients. If an internal mammary sampling is not performed, patients may be understaged. This technique may allow better selection of those patients who will be submitted to adjuvant locoregional radiotherapy.

Primary Breast Cancer Features Can Predict Additional Lymph Node Involvement in Patients with Sentinel Node Micrometastases

OBJECTIVE

The aim of this retrospective study was to identify biological features of primary breast cancer from which to predict the presence of further axillary involvement in patients bearing micrometastases in the sentinel lymph node (SLN).

METHODS

From a starting group of 690 patients, we isolated patients with micrometastases in the SLN. Those patients were classified according to the presence/absence of further metastases in nonsentinel lymph nodes (NSLNs). We examined primary tumor features to identify any relevant difference. Analysis of primary tumors evaluated histology, tumor size, lymphovascular invasion, mitotic index (Mib-1), estrogen and progesterone receptor status (ER/PR status), C-erb B-2 (HER-2/neu) expression and amplification, and p53 expression. Chi square analysis for statistical significance was applied.

RESULTS

Of the original 690 patients, 296 showed some kind of metastases in the SLN; 238 patients had gross metastases in the SLN. After axillary lymph node dissection (ALND), 102 patients (43%) had NSLNs with metastases, and 136 (57%) had negative axillary non-sentinel nodes. Another 58 patients harbored solitary micrometastases in the SLN. After ALND, 8 (14%) patients had further NSLN involvement, and 50 (86%) had negative axillary nodes.

CONCLUSIONS

Analysis of the primary breast lesion in patients with micrometastatic SLN and metastatic NSLNs revealed the presence of lymphovascular invasion, Mib-1 index > 10%, and tumor size > 2 cm. Patients without lymphovascular invasion, Mib-1 < 10% and T size < 2 cm could avoid further ALND.

Accuracy and reliability of sentinel node biopsy in patients with breast cancer. Single centre study with long term follow-up

The aim of our study is to evaluate the frequency of false-negative (FN) sentinel node procedures in patients with breast cancer. A total of 791 breast cancer patients underwent sentinel lymph node (SLN) biopsy at our institution between July 1997 and February 2005. A 2-day protocol was used to localise the sentinel node with the injection of 99mTc-nanocolloid. There were two phases in the study: the learning phase (50 patients) and the application phase (741 patients). In the learning phase, a complete lymphadenectomy was always performed. In the application phase, sentinel nodes were studied postoperatively with breast cancer and lymphadenectomy was performed when considered warranted by the pathological postoperative results. The median follow-up duration in the 741 patients studied during the application phase was 32.3 months (range 6-72 months). In this phase a total of 787 sentinel nodes (719 axillary and 68 intramammary chain) were obtained (range 0-5 per patient, mean 1.01), with 153 (41 with micrometastasis) positive sentinel nodes. We observed a total of three FN SLN results (0.5%). All three presented as an axillary recurrence into 24 months from operation. After a median follow-up of 32.3 months we observed only three clinical recurrences among 741 patients. Our results indicate that the sentinel node protocol can give an adequate local control.

A new approach to the cure of the Ogilvie's syndrome

The Authors describe a their own observation of 25 cases of acute colonic pseudo obstruction, better known as "Ogilvie Syndrome" with the objective to demonstrate that an early recognition and prompt appropriate therapy, better if conservative, can reduce the morbidity and the mortality of the Syndrome. The surgical therapy is reserved only to that cases in which the risk of perforation of the cecum represent an absolute indication to intervention.

Thoracoscopic Localization Techniques for Patients with a Single Pulmonary Nodule and Positive Oncological Anamnesis: A Prospective Study

INTRODUCTION

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with a single pulmonary nodule and a history of malignancy.

METHOD

We divided 30 patients into two groups, well matched for diameter and depth of the pulmonary lesion. In 15 patients (group A) we performed intrathoracoscopic ultrasound (US) to locate the pulmonary nodule, while in the other 15 patients (group B) intrathoracoscopic radioguided occult lesion localization (ROLL) was used. In both groups, the localization technique was compared to finger palpation. In group A, 6 nodules were in the left lung and 9 in the right; in group B, 7 lesions were in the left and 8 in the right lung. In each group, the distance of the nodule from the pleural surface was 2-2.5 cm in 8 patients, and > 2.5 cm in the remaining 7. In both groups, the diameter of the nodule was </= 1 cm in 6 patients, and 1-1.5 cm in 9 patients. All patients underwent thoracoscopic wedge resection, and 6 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.

RESULTS

In group A, US localized the nodule in 15 of 15 patients (100%) while finger palpation located the nodule in 11 of 15 (73%) (P = NS). In group B, both ROLL and finger palpation localized the nodule in 12 of 15 patients (80%) (P = NS).

CONCLUSION

Intrathoracoscopic US seems superior to radioguided and finger palpation localization techniques for single pulmonary nodules. Thus, we are now routinely using intraoperative US to identify single pulmonary nodules.

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.

STUDY DESIGN

This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.

RESULTS

In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.

CONCLUSIONS

Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

Acute colon diverticulitis in multiple myeloma patient: an unusual presentation of a colonic perforation. Case report

This case report describes an acute colonic diverticular perforation occurred to a multiple myeloma patient, taking corticosteroid and morphine therapy, revealed by a subcutaneous emphysema of upper chest and right abdomen as initial presentation. Sigmoid diverticulitis with perforation and generalized peritonitis is a severe complication of the diverticular disease and it is due to diverticular microperforation. This condition occurs more frequently in patients with widespread diverticolosis and usually after 50 years of age, and the frequency of related complications increases with age (and with the use of corticosteroids). Extraperitoneal air from the sigmoid-rectum perforation can escape diffusing superiorly though paravertebral retroperitoneal tissues and via the diaphragmatic iatus into the mediastinum, producing pneumomediastinum and it diffuses to yield superior thoracic emphysema. This report suggests that the diagnosis of retroperitoneal perforation is usually difficult because of the lack of signs of peritoneal irritation and the paucity of symptoms, particularly in patients treated with corticosteroids.

A new device for sutureless skin closure "the zipper"

BACKGROUND

We have done a prospective, controlled, randomized study to investigate the role of the "zipper", a new device for skin closure. We have also analysed morbility and advantages with the use of the "zipper" compared with sutures.

METHODS

610 consecutive patients underwent surgery for abdominal thoracic endocrinologic and post traumatic pathologies. In 203 cases we used the zipper a new device for skin closure.

RESULTS

6/203 Morbility: in six cases it was necessary to substitute the zipper with sutures or leave the wound healing by second intention. The patients were operated for inguinal hernioplasty, axillary lymphadenectomy, appendicectomy and cholecystectomy. These patients developed complications after surgery as hematoma, lymphorrhea, wound infection and a reintervention. The correction has been done removing the zipper and positioning sutures or leaving the wound healing by second intention.

CONCLUSIONS

The use of the zipper permits to achieve an efficient seal, a simple application, an aesthetic comfort; it can be applied in local anaesthesia and for its painless, application it is indicated in pediatric surgery.

An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation

A modern approach to the surgical treatment of early breast carcinoma requires intraoperative localisation of non-palpable lesions and assessment of the lymph node status. Localisation of breast lesions can be achieved by intratumoural injection of a small amount of radiotracer and intraoperative use of a gamma probe (i.e. radioguided occult lesion localisation, or ROLL). Assessment of the lymph node status is possible by means of the sentinel node approach. To date, two different radiopharmaceuticals have been used for localisation of tumour and sentinel node. We now propose the use of a single nanocolloidal tracer (Nanocoll, with a particle size of less than 80 nm) which is labelled with technetium-99m for simultaneous performance of ROLL and sentinel node identification. The aim of this study was to evaluate the feasibility of this approach, which should be easier and more practical than the dual-tracer injection method. We have employed this new technique in 73 patients with non-palpable, cytologically diagnosed breast cancer and non-palpable axillary lymph nodes. In all patients the radiocolloid, in a total volume of 0.3-0.4 cc, was injected under sonographic or stereotactic guidance. Half of the dose was injected intratumourally and half superficially, but very close to the tumour. Because of the slow lymphatic flow in the breast, Nanocoll must be injected some time before surgery in order to enable adequate migration to the axilla. We injected colloid in the afternoon before surgery (16-23 h before the start of the operation, with an average interval of 18 h). An average dose of 130 MBq (range 110-150) was injected in order to have about 10 MBq of radioactivity when surgery commenced. Lymphoscintigraphy was performed after 15-19 h, with an average interval of 17 h. The procedure was always successful in permitting the localisation of occult breast lesions. Lesions were always localised at the first attempt, and were always contained within the surgical margins. Histological examination revealed all 73 resected lesions to be malignant: there were 64 cases of infiltrating carcinoma and nine of intraductal carcinoma. All breast lesions were therefore confirmed to be early breast cancer. We achieved sentinel node localisation in 71 out of 73, either at scintigraphy or with the intraoperative probe; in two patients, radiopharmaceutical migration was absent. Lymphoscintigraphy showed only axillary drainage in 52 cases, only internal mammary chain (IMC) drainage in nine cases, and combined axillary and IMC drainage in eight cases. In two cases, lymphoscintigraphy suggested the sentinel node was located inside the same breast (intramammary lymph node). All the visualised sentinel nodes were biopsied except for four that were localised in the IMC. Histological examination of the nodes showed metastases in 20 cases: in 15 cases there were micrometastases, and in five, macrometastases. In conclusion, this study has demonstrated the feasibility of the proposed procedure. Simultaneous performance of ROLL and sentinel node localisation using a single tracer represents a useful and practicable choice in the management of early breast cancer.