Introduction.

There is no doubt that postgraduate education and all "professional development activity" is in crisis, not only in our country but in all of Europe. The crisis is on one hand due to a lack of resources which has been evident for more than a decade, and on the other hand due to factors such as organization, culture, and education. Many of the chief medical disciplines such as internal medicine or general surgery, have been literally crushed and replaced by a myriad of subspecialties that have undermined the original unified character of the main disciplines 1.

Association of Lymph Node Status With Survival in Patients After Liver Resection for Hilar Cholangiocarcinoma in an Italian Multicenter Analysis.

Importance: The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined.

Objectives: To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging.

Design, Setting, And Participants: Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers.

Refractory hepatic lymphorrhea after total pancreatectomy. Case report and literature review of this uncommon complication.

Introduction: After extended abdominal lymphoadenectomy, lymphatic vessel injury may cause lymphorrhea that usually disappears spontaneously. However, intractable ascites sometimes develops. Although there are many reports describing persistent chylous ascites from intestinal lymphorrhea, little is known about hepatic lymphorrhea, not containing chyle.

Parietal and peritoneal localizations of hepatocellular carcinoma: is there a place for a curative surgery?

Background: The clinical course of peritoneal and parietal recurrence of hepatocellular carcinoma (HCC-PPL) is not well known.

Methods: Twenty-eight patients with a histologically proven HCC-PPL were analyzed out of a series of 515 patients operated for HCC (group 1). The risk factors, histological features, growing dynamic and results of surgical treatment were analyzed and compared with patients having other extrahepatic localizations of HCC (group 2; 26 patients).

Impact on liver cancer treatment of a first erroneous diagnosis of hemangioma.

Background: Most liver hemangioma (HA) diagnoses are presumptive and based on radiological features and growth trend. The goal of this study was to analyze the impact of a false diagnosis of hemangioma upon the overall therapeutic course and upon the prognosis of a liver malignancy.

Methods: Twenty-eight patients with liver cancer who were observed in the period 2001-2007 after an initial erroneous diagnosis of HA were retrospectively evaluated.

Multiple primary malignancies of the liver and the colon: a complex diagnostic and decisional process with a final unanswered question.

We herein present the case of a 78-year-old man with an incidental finding of a solid hepatic mass without symptoms and only a laparotomic cholecystectomy for acute cholecystitis in the past surgical history. A colonoscopy, a magnetic resonance imaging scan, a positron emission tomography scan, and a computed tomography scan completed the preoperative workup: a neoplastic lesion 4.3×3 cm in size was diagnosed at segments IV and V, associated with a neoplastic involvement of the splenic flexure without signs of colonic occlusion.

Lynch syndrome from a surgeon perspective: retrospective study of clinical impact of mismatch repair protein expression analysis in colorectal cancer patients less than 50 years old.

Background: In clinical practice, unexpected diagnosis of colorectal cancer in young patients requires prompt surgery, thus genetic testing for Lynch Syndrome is frequently missed, and clinical management may result incorrect.

Methods: Patients younger than 50 years old undergoing colorectal resection for cancer in the period 1994-2007 were identified (Group A, 49 cases), and compared to a group of randomly selected patients more than 50 (Group B, 85 cases). In 31 group A patients, immunohistochemical expression analysis of MLH1, MSH2 and MSH6 was performed; personal and familial history of patients with defective MMR proteins expression was further investigated, searching for synchronous and metachronous tumors in probands and their families.

Follow-up after gastrectomy for cancer: an appraisal of the Italian research group for gastric cancer.

Background: The Italian Research Group for Gastric Cancer supports the practice of follow-up after radical surgery for gastric cancer.

Methods: This multicenter, retrospective study (1998-2009) included patients with T1-4N0-3M0 gastric cancer who had undergone D2 gastrectomy and lymphadenectomy, with at least 15 lymph nodes examined, and who had developed recurrent disease. Timing and site of recurrence were correlated to the actual scheduled follow-up timing and modalities.

The SIC-GIRCG 2013 Consensus Conference on Gastric Cancer.

The topic chosen by the Board of the Italian Society of Surgery for the 2013 annual Consensus Conference was gastric cancer. With this purpose, under the direction of 2 chairmen, 36 experts nominated by the Regional Societies of Surgery and by the Italian Research Group for Gastric Cancer (GIRCG) participated in an experts consensus exercise, preceded by a questionnaire and mainly held by telematic vote, in accordance with the rules of the Delphi method. The results of this Consensus Conference, presented to the 115th National Congress of the Italian Society of Surgery, and approved in plenary session, are reported in the present paper.

Microvascular infiltration has limited clinical value for treatment and prognosis in hepatocellular carcinoma.

Background: Microvascular infiltration (MVI) is considered a necessary step in the metastatic evolution of hepatocellular carcinoma (HCC), but its prognostic value after liver resection (LR) is uncertain. We studied the clinical value of MVI compared to the Milan criteria in a consecutive series of patients submitted to radical LR.

Methods: A total of 441 patients were retrospectively evaluated.

Peritoneal carcinomatosis.

Several gastrointestinal and gynecological malignancies have the potential to disseminate and grow in the peritoneal cavity. The occurrence of peritoneal carcinomatosis (PC) has been shown to significantly decrease overall survival in patients with liver and/or extraperitoneal metastases from gastrointestinal cancer. During the last three decades, the understanding of the biology and pathways of dissemination of tumors with intraperitoneal spread, and the understanding of the protective function of the peritoneal barrier against tumoral seeding, has prompted the concept that PC is a loco-regional disease: in absence of other systemic metastases, multimodal approaches combining aggressive cytoreductive surgery, intraperitoneal hyperthermic chemotherapy and systemic chemotherapy have been proposed and are actually considered promising methods to improve loco-regional control of the disease, and ultimately to increase survival.

A drastic complex atheromatous aorta. A case report.

Aortic atherosclerosis is the most common disease of the aorta. More than 50% of the plaques thicker than 4 mm are located along the descending aorta. The complex morphology of the plaque, such as ulceration or the presence of thrombi, is associated with increased embolic risk.

Factors influencing outcomes in laparoscopic adrenal surgery.

Purpose: This study aims to recognize factors affecting operative and postoperative outcomes in patients undergoing unilateral laparoscopic adrenalectomy performed by using the transabdominal approach.

Methods: From a prospectively collected adrenal database, we performed a retrospective analysis of all patients undergoing unilateral adrenalectomy from July 2002 to December 2011. The outcome measures considered were the following: conversion rate, intra- and postoperative complications, duration of surgery, length of hospital stay, and return-to-work time.

Long-term effectiveness of resection and radiofrequency ablation for single hepatocellular carcinoma ≤3 cm. Results of a multicenter Italian survey.

Background & Aims: The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤3 cm and compensated cirrhosis.

Methods: The study involved 544 Child-Pugh A cirrhotic patients (246 in the resection group and 298 in the radiofrequency group) observed in 15 Italian centers. Overall survival and tumor recurrence rates were analyzed using the Kaplan Meier method before and after propensity score matching.

Sequential multiple visceral arteries dissections without aortic involvement.

Isolated dissection of visceral arteries without associated aortic pathology is very rare. Risk factors, etiology, and natural history of this pathology continue to be unclear, and the guidelines for clinical management remain to be defined. We present a case not described previously, with sequential dissections of the celiac trunk, superior mesenteric artery, and renal arteries without aortic involvement.

Management of pancreatic intraductal papillary mucinous neoplasm in an academic hospital (2005-2010): what follow-up for unoperated patients?

Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection.

Methods: Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology.

Association between human parainfluenza virus type 1 and smoking history in patients with an abdominal aortic aneurysm.

Several studies have suggested that infectious agents may induce the development of abdominal aortic aneurysms and/or accelerate their progression. The aim of this study was to evaluate the presence of the respiratory-transmitted viruses such as influenza A and B and parainfluenza type 1 genomes in bioptic fragments of abdominal aortic aneurysms. Furthermore, the association between viral infection and traditional risk factors for aneurysms was investigated employing multivariate logistic regression models.

Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treatment for the infection of crossover bypass in aorto-uni-iliac endovascular aneurysm repair.

The crossover femoro-femoral bypass, classically used for the treatment of unilateral iliac arterial obstruction, has recently become an integral part of aorto-uni-iliac endovascular aneurysm repair. We therefore, reconsider the therapeutic problems related to thrombosis and in particular to infection of the femoro-femoral prosthesis, when many attempts have been made to preserve the bypass and treat the infection. Showing a case treated and well eight months later, we put forward the old technique of crossover ilio-iliac bypass, followed by the removal of the infected femoro-femoral graft.

Surgical Approach for Long-term Survival of Patients With Intrahepatic Cholangiocarcinoma: A Multi-institutional Analysis of 434 Patients.

OBJECTIVES To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and to clarify the prognostic impact of a lymphadenectomy and the surgical margin. Large series of patients who were surgically treated for IHC are scarce. Thus, prognostic factors and long-term survival after resection of IHC remain uncertain.

Searching for indicators of malignancy in pancreatic intraductal papillary mucinous neoplasms: the value of 18FDG-PET confirmed.

Background: Malignancy in intraductal papillary mucinous neoplasms (IPMN) of the pancreas may be predicted on the basis of a number of clinical and radiologic features, which have raised sensitivity but result in a specificity as low as 20-50%. We sought to confirm the additional value of (18)F-18-fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) in diagnostic accuracy of imaging-based IPMN malignancy assessment.

Methods: This prospective uncontrolled case series contained 44 patients with IPMN undergoing comprehensive diagnostic evaluation, including magnetic resonance cholangiopancreatography and (18)FDG-PET.

Prospective randomized comparison of open versus laparoscopic management of splenic artery aneurysms: a 10-year study.

BACKGROUND: The literature does not support the choice between open and laparoscopic management of splenic artery aneurysms (SAA). METHODS: We designed a prospective, randomized comparison between open and laparoscopic surgery for SAA. Primary end points were types of surgical procedures performed and clinical outcomes.

Transforming growth factor-beta1 induces microvascular abnormalities through a down-modulation of neural cell adhesion molecule in human hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a very angiogenic and malignant cancer. Conventional chemotherapy is poorly effective because of the abnormal structural organization of HCC-infiltrating vessels. In previous work, we demonstrated that HCC angiogenesis is driven by transforming growth factor beta-1(TGF-β1)/CD105 axis, stimulating liver-derived microvascular endothelial cells (Ld-MECs) migration.

Liver resection for hepatocellular carcinoma ≤3 cm: results of an Italian multicenter study on 588 patients.

Background: The best treatment for patients with small hepatocellular carcinoma (S-HCC) is still controversial. The aim of this study was to evaluate operative and long-term results after liver resection (LR) for S-HCC, defined as tumor ≤3 cm.

Study Design: Retrospective multicenter study of 588 LRs for S-HCC from 8 Italian hepatobiliary surgery units (years 1992 to 2008).