Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: a large retrospective cross-sectional study.

BACKGROUND: Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications. AIMS: The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture. METHODS: We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course. RESULTS: Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding. CONCLUSION: Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.Peer reviewe

Valutazione di fattori prognostici nel trattamento integrato dei GIST

Gastrointestinal stromal tumors (GIST) are mesenchymal tumorssupposed to arise from the cells of Cajal for mutations of the tyrosine re-ceptor kinases c-kit or platelet-derived growth factor receptor A. Ima-tinib selectively inhibits the kinase activity. Surgical treatments includ-ing radical resection and local excision remain the main treatment forprimary gastrointestinal stromal tumors (GISTs). Patients with high-grade GISTs have a higher risk of tumor recurrence and a shorter lifeexpectancy the introduction of Imatinib had changed drammaticallythe natural history of that kind of tunors, expecially in non-resectabletumors. AIM: we try to find the relationship between the tumor chara-teristics (size,mitosis, risk group, clinical sign and symptoms) and theoutcome (disease free survival and overall survival). Methods: from2001 to 2007, 20 patients (11 m/9 f) median age 68.9 (range 50-83yrs) underwent surgery for GIST resection, occasional diagnosys wasperformed in 3 patients. 15 were primary GIST, 2 recurrence localizedin ileum. Was performed 9 wedge gastric resections, 1 gastric resection,11 ileal resection. Main tumor size was 7.1 cm +/- 5, tumor necrosiswas found in 2 cases. After a median follow-up of 55.3 months (39.4-71.2) We stratify the patiens in risk group and we observed a statisticrelatrionship between tumor size and mitosis ane DFS and OS. Con-clusion: even in a small group surgical excision of low- and intermedi-ate-grade GIST has an excellent prognosis. Surgery remains the main-stay of treatments, and high-grade tumours carry a significantly worseprognosis. High mitotic rates and size are important poor prognostica-tor

Risk stratification systems for surgically treated localized primary Gastrointestinal Stromal Tumors (GIST). Review of literature and comparison of the three prognostic criteria: MSKCC Nomogramm, NIH-Fletcher and AFIP-Miettinen.

PURPOSE: The discovery of Imatinib mesylate (Gleevec®) has revolutionized the treatment of GIST, increasing disease-free survival (DFS) after complete surgical resection of a primary localized GIST and extending overall survival in metastatic disease. The definition of an accurate prognostic system is critical for the therapeutic decision making process. In literature, there are three main prognostic criteria F/NIH consensus, AFIP standards and modified NIH standards. In recent years were added various risk identification methods applying mathematical calculation model, including MSKCC risk nomogram, Rossi nomogram and Joensuu high Hotline Dengjun. Despite all these attempts, it seems that the recurrence risk probability still cannot be predicted accurately. The aim of our study was to assess and compare the real ability of these prognostic instruments in our single-centre clinical experience, and to define if the use of the MSKCC nomogram can bring benefits in the therapeutic decision. METHODS: All data regarding 37 GIST, who underwent surgical resection from 1996 to 2011 in our institution were retrospectively reviewed. We selected only primary GIST without metastatic disease who underwent a radical resection (R0) but no other therapy. The literature data concerning GISTs prognostication criteria were reviewed. All patients were classified according to the three prognostic criteria (NIH, AFIP and Nomogram MSKCC) and the three instruments were compared with the Kaplan-Meier method. Then we compared the three criteria for their c-index value and we assessed the performance of the nomogram with the calibration test. RESULTS: We observed 9 recurrences (24%) with an average time to relapse of 43 months; the median follow-up was 65 months. In the study selected sample occurred 5 relapses. The probability of relapsing after radical surgery was 7.9% (95% CI 0-17.3) at 2 years and 13.3% at 5 years (95% CI 0-26.4). The C-Index of the three risk assessment tools was 0.93 (95% CI 0.83-1) for the Nomogram at 5 years, 0.86 (95% CI 0.76-0.95) for the NIH risk criteria and 0.88 (95% CI 0.74-1) for the AFIP risk criteria. The calibration analysis of the nomogram showed an overestimating trend both at 2 and 5 years. CONCLUSION: MSKCC nomogram seems to perform better than NIH, NIH modified and AFIP in our sample and can be used in clinical practice to predict the risk of recurrence, being especially helpful for the therapeutic decision making since it is at the same time simple to use and accurate. As showed from calibration, MSKCC doesn't seem to neglect relapses, even though it is not impeccable in predicting the RFS. Among the 2 older criteria AFIP was more precise than NIH, but considering size in not linear way represented a limit in comparison with the MSKCC Nomogram. All the three risk assessement tools criteria considered are capable to predict recurrence in high-risk GISTs while they performed worse in those with lower risk. MSKCC nomogram main limit remains the not linear consideration of mitotic count

May the drain be a way in for microbes in surgical infections?

Background Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains. Methods This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI. Findings A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99). Conclusion This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions

Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients

BACKGROUND: Recent evidence has shown that enhanced recovery after surgery (ERAS) protocols decrease hospital stay following pancreaticoduodenectomy (PD). The aims of this study were to assess the feasibility and to evaluate the effect of introducing ERAS principles after PD in elderly patients. METHODS: Patients ≥75 years were defined as elderly. Comparison of postoperative outcome was performed between 22 elderly patients who underwent ERAS (elderly ERAS + patients) and a historical cohort of 66 elderly patients who underwent standard protocols (elderly ERAS-patients). RESULTS: The lowest adherence with ERAS among elderly patients was observed for starting a solid food diet within POD 4 (n = 7) and early drains removal (n = 2). The highest adherence was observed for post-operative glycemic control (n = 21), epidural analgesia (n = 21), mobilization (n = 20) and naso-gastric removal in POD 0 (n = 20). Post-operative outcomes did not differ between elderly ERAS+ and elderly ERAS- patients. In patients with an uneventful postoperative course, the median intention to discharge was earlier in elderly ERAS + patients as compared to the elderly ERAS- patients (4 days versus 8 days, P < 0.001). CONCLUSION: An ERAS protocol following PD seems to be feasible and safe among elderly although it is not associated with improved postoperative outcomes