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26.  Laparoscopic adrenal surgery: ten-year experience in a single institution 
BMC Surgery  2013;13(Suppl 2):S5.
Background
Minimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit.
Methods
We retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn's disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed.
Results
Forty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn's patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma.
Conclusions
LA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.
doi:10.1186/1471-2482-13-S2-S5
PMCID: PMC3850966  PMID: 24267584
27.  Early postoperative administration of probiotics versus placebo in elderly patients undergoing elective colorectal surgery: a double-blind randomized controlled trial 
BMC Surgery  2013;13(Suppl 2):S57.
Background
Perioperative prophylactic antibiotic treatment significantly influences intestinal microflora, resulting in impaired bowel functioning in some patients, sometimes requiring further investigations. This may lead to a worse health-related quality of life (HRQoL). Probiotics administrated in the early post-operative period may help avoiding such nuisances in older people.
Methods
We prospectively enrolled patients undergoing laparoscopic colorectal surgery aged over 70 years between 2005 and 2012. The study was approved by IRB. All patients received perioperative antibiotic treatment. Patients were randomized to one of two treatment arms: Group A patients received probiotics after surgery (VSL#3, VSL Pharmaceuticals, Inc. USA - 900 × 109 daily, while Group B patients received a Placebo (cornstarch). Patients were further divided in sub-groups whether ileo-caecal valve was spared or not. Patients were followed-up every 7 days for 4 weeks. Patients daily annotated bowel frequency, stool shape and consistency - according to Bristol's scale. HRQoL was assessed every week by means of SF-36 questionnaire.
Results
Group A included 10 while Group B included 8 patients. One patient in each group experienced a postoperative complication. Group A patients had fewer bowel movements than controls, during every week. Stool consistency was higher in patients undergoing resections including ileo-caecal valve receiving VSL#3. HRQoL gradually increased in both groups; Group A patients had higher "social functioning" item scores at week 1 and 4 than controls.
Conclusions
Elderly patients undergoing resection of ileo-caecal valve may benefit from an early probiotics administration pathway after perioperative antibiotic treatment.
doi:10.1186/1471-2482-13-S2-S57
PMCID: PMC3850968  PMID: 24268034
28.  Short-time prone posturing is well-tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment 
BMC Surgery  2013;13(Suppl 2):S55.
Purpose
To evaluate the feasibility, efficacy and safety of strict prone posturing taken for 2 hours after operation in preventing the occurrence of unintentional retinal displacement in elderly patients operated on for retinal detachment (RD).
Methods
Twenty patients aged 60 or more with diagnosis of macula-off RD were asked to keep a strict face-down posturing for 2 hours after vitrectomy and 20% sulfur hexafluoride tamponade. IOP was measured immediately before and after surgery and after the 2-hour posturing. A questionnaire was administered to each patient to evaluate the rate of discomfort experienced because of the face-down posturing. Unintentional displacement of the retina was assessed by evaluating the presence of retinal vessel printings on fundus autofluorescence images taken 4 weeks after operation.
Results
The 2-hour posturing was generally well-tolerated. A mild neck pain was the most common reported symptom. Only a few patients experienced moderate breath shortness while posturing and none had to break the posturing because of respiratory problems. Intraocular pressure (IOP) measured before operation (11.7 ± 2.6 mmHg) was significantly different from IOP recorded at the end of surgery (18.9 ± 4.9 mmHg) and from IOP measured 2 hours after surgery (16.8 ± 4.7 mmHg, P<0.05, Friedman test). IOPs measured immediately and 2 hours after surgery did not differ significantly. Fundus autofluorescence imaging showed RVPs in 7 eyes.
Conclusions
This study shows that a 2-hour face-down posturing is effective in reducing the rate of retinal displacement in patients operated on for rhegmatogenous retinal detachment using vitrectomy and SF6 20%. A 2-hour face-down posturing is feasible for elderly patients and does not appear to cause unwanted, post-operative IOP raises.
doi:10.1186/1471-2482-13-S2-S55
PMCID: PMC3850981  PMID: 24267923
29.  Diagnosis of incidental gallbladder cancer after laparoscopic cholecystectomy: our experience 
BMC Surgery  2013;13(Suppl 2):S20.
Background
Gallbladder carcinoma is a rare high malignancy neoplasm. The incidence of intra or post-operative incidental gallbladder carcinoma diagnosis is estimated between 0,2 and 2,8%. Primary aim of our study is to evaluate incidental gallbladder carcinoma's incidence in our experience.
Methods
We retrospectively reviewed our Surgery Division's experience about the totality of laparoscopic cholecystectomies with post-operative histological evidence of incidental gallbladder cancer. We evaluated patients' characteristics, surgical related variables, histological response, surgivcal radicalization characteristics and surgical outcome.
Results
In the considered sample we observed 7 accidental gallbladder adenocarcinomas in post-operative histological examination. Pathological results were:1 pT1b N0 (G1), 2 pT2 N0 (G2), 2 pT2 N1 (G3b), 2 pT3 N1 (G3b) (Table 1). In 5 cases we performed neoplasm radicalization surgery with standard procedure revision. Two patients died before radicalization. Median global survival was 34 months.
Conclusion
With the increase of laparoscopic cholecystectomies both elective and urgent performed in our centre we observed also an increase of incidentally diagnosed gallbladder neoplasms. Early diagnosis, meticulous peri-operative study and accurate surgical strategy are essential factors to obtain good results in incidental gallbladder cancer.
doi:10.1186/1471-2482-13-S2-S20
PMCID: PMC3850984  PMID: 24268097
30.  Minimal invasive surgery in treatment of liver metastases from colorectal carcinomas: case studies and survival rates 
BMC Surgery  2013;13(Suppl 2):S45.
Background
Liver represents the main organ subject to metastases from colorectal tumors. Resections of liver metastases from colorectal cancer have a well-considered therapeutic role underlined by survival of 5 years by approximately 50-60% of surgical cases as is deduced from an analysis of the most recent literature. The objective of surgery is to eradicate the metastases present and obtain a margin free from neoplastic impact of amplitude of approximately 1 cm with residual liver quantity at the end of the intervention that allows the patient to survive. Currently the dimensions and the number of colorectal liver metastases (CRLM) do not limit the hepatectomy. Purpose of this work is to evaluate the survival, according to our case studies of patients treated only with the wedge resection (atypical resection) approximately 1 cm from the margins of metastases.
Methods
In "A. Rizzoli" Lacco Ameno Hospital (Ischia), from 2005 to 2010, 12 liver resections were performed for metastases from colorectal carcinoma with atypical resection. Synchronous surgical treatment with resection of the colorectal carcinoma and metastases was performed in 6 patients, 2 female and 4 male (Group 1). Surgical liver metastasectomy post-colectomy was performed on 6 patients, 3 female and 3 male (Group 2).
Results
No patient was treated with chemotherapy. The mortality rate of intraoperative and perioperative infection was in both cases of 0%. Survival:11 patients treated surgically from 2005-2010 with synchronous surgery resection (Group 1) and liver metastasectomy (Group 2) are currently living. One 77-years-old patient died three years after surgery for BPCO.
Conclusions
This result was able to be obtained due to the wedge resection technique routinely used in our Hospital, associated with the indispensable use of intraoperatory ultrasound (IOUS). Significant differences between the synchronous and non-synchronous intervention emerged only regarding the number of days of hospital stay, higher in the first case.
doi:10.1186/1471-2482-13-S2-S45
PMCID: PMC3850987  PMID: 24267179
31.  Mediterranean diet and cancer: epidemiological evidence and mechanism of selected aspects 
BMC Surgery  2013;13(Suppl 2):S14.
Background
Populations living in the area of the Mediterranean Sea suffered by decreased incidence of cancer compared with those living in the regions of northern Europe and US countries, attributed to healthier dietary habits. Nowadays, we are assisting to a moving away from the traditional Mediterranean dietary pattern, but whether this changing is influencing risk of cancers is still unclear. The aim of the study was to review recent evidence on potential relationship between the adherence to the Mediterranean diet and cancer.
Discussion
The most recent pooled analyses of epidemiological studies supported strongly the hypothesis that the Mediterranean diet may play a role in preventing several types of cancers, especially those of digestive tract, whereas contrasting results were reported for hormone-dependent cancers. Specific aspects of the Mediterranean diet such as high fruit and vegetables and low red processed meat intake may explain such protective effects. Moreover, evidence regarding olive oil and whole grains increase the beneficial effects of such dietary pattern against cancer.
Conclusions
Literature evidence actually demonstrates that the increased adherence to the Mediterranean dietary pattern is beneficial to health across populations and may translate a protective effect with certain cancers.
doi:10.1186/1471-2482-13-S2-S14
PMCID: PMC3850991  PMID: 24267672
32.  Cytological diagnosis of adult-type fibrosarcoma of the neck in an elderly patient. Report of one case and review of the literature 
BMC Surgery  2013;13(Suppl 2):S42.
Background
Fibrosarcoma (FS) accounts for about 3% of all soft tissue sarcomas. It may arise in any area of the body, but it is relative rare in the head and neck district. Fine-needle cytology (FNC) is widely used in the diagnosis of neoplastic and non-neoplastic lesions of soft tissue. This article describes a case of FS of the neck diagnosed by FNC.
Methods
FNC was performed in a sub-fascial supraclavicular mass of an elderly patient under ultrasound (US) control. FNC was used to prepare cytological smears that were conventionally and immunocytochemically (ICC) stained.
Results
Smears showed a monomorphous spindle cell population and were positive at ICC for Vimentin and negative for CKAE1AE3, Actin, S-100, CD68, CT and PAX-8. The cytological diagnosis was confirmed by histological diagnosis. The patient underwent surgical resection and subsequent radiotherapy.
Conclusions
FNC diagnosis of FS is reliable and accurate and may be conveniently used in the scheduling of surgical procedures, when needed, avoiding the treatment of benign nodules.
doi:10.1186/1471-2482-13-S2-S42
PMCID: PMC3850999  PMID: 24266985
33.  An unusual case of primary choriocarcinoma of the lung 
BMC Surgery  2013;13(Suppl 2):S33.
Choriocarcinoma is a germ cell tumor containing syncytiotrophoblastic cells and secreting human Beta-HCG. Primary choriocarcinoma of the lung is extremely uncommon. The prognosis of this tumor is extremely poor, despite surgical and chemotherapeutic treatment. We report a surgically treated case of choriocarcinoma in a 37-year-old woman who came to our attention because of a isolated lung lesion. The tumor was successfully resected. Chemotherapy was started 2 months after thoracic surgery and consisted of bleomycin, etoposide, and cisplatin. At 1-year follow-up the patient is alive in good condition. The hCG level is actually normal.
doi:10.1186/1471-2482-13-S2-S33
PMCID: PMC3851001  PMID: 24267667
Choriocarcinoma; Lung
34.  Glottic-SubGlottic adenoid cystic carcinoma. A case report and review of the literature 
BMC Surgery  2013;13(Suppl 2):S48.
Background
Malignant tumours of minor salivary glands are uncommon, representing only 2-4% of all head and neck cancers. In the larynx, minor salivary gland tumours rarely occur and constitute less than 1% of laryngeal neoplasm. Most of the minor salivary gland tumours arise in the subglottis; however, they can also occur in the supraglottis, in the false vocal cords, aryepiglottic folds and caudal portion of the epiglottis. The most common type of malignant minor salivary gland tumour is adenoid cystic carcinoma.
Methods
We present a unusual case of adenoid cystic carcinoma of glottic-subglottic region in a 61-year-old woman. Follow-up endoscopy and laryngeal magnetic resonance imaging (MRI) at three years after treatment showed no recurrence of the tumour.
Results
The diagnosis of glottic-subglottic adenoid cystic carcinoma should be considered in patients who are characterized by dyspnea, cough and stridor, but do not respond to pharmacologic approach.
Conclusions
Adenoid cystic carcinoma is usually a very slow growing cancer, invested by an apparently normal laryngeal mucosa, so that it can show no clear symptoms for a long time. For these reasons the increasing number of diagnostic mistakes or late diagnosis that may be fatal in some cases.
doi:10.1186/1471-2482-13-S2-S48
PMCID: PMC3851004  PMID: 24427787
35.  Microvascular free-flap transfer for head and neck reconstruction in elderly patients 
BMC Surgery  2013;13(Suppl 2):S27.
Background
With the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention.
Methods
We retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population.
Results
Twenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population.
Conclusion
This study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.
doi:10.1186/1471-2482-13-S2-S27
PMCID: PMC3851005  PMID: 24267178
36.  How the preoperative ultrasound examination and BFI of the cervical lymph nodes modify the therapeutic treatment in patients with papillary thyroid cancer 
BMC Surgery  2013;13(Suppl 2):S52.
Background
Ultrasound is considered the best diagnostic method for the detection of metastatic cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). According to current guidelines, all patients undergoing thyroidectomy for malignancy should undergo preoperative neck ultrasound of the thyroid and central and lateral neck LNs, followed by fine needle aspiration of suspicious LNs. Cervical LN involvement determenes the extent of surgery. Complete surgical resection disease at the initial operation decreases likelihood of future surgery for recurrent disease and may impact survival. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC.
Methods
Between September 2006 and December 2012, 304 patients with known PTC were examined for preoperative sonographic evaluation with gray-scale US, color Doppler US and BFI. Only 157 with at least one metastatic LN were included in our study. All patients included underwent surgery, and the final diagnosis was based on the results of histologic examination of the resected specimens. The following LN characteristics were evaluated: LN shape, abnormal echogenicity, the absent of hilum, calcifications, cystic appearance, peripheral vascularization and the presence of BFI-TS.
Results
A total of 767 LNs were analyzed. 329 out of 767 were metastatic, according to the histopathologic findings. BFI-TS, showed 99.5% specificity and 81,5% sensitivity. We detected BFI-TS in 6 metastatic LNs that were negative to the other conventional US features.
Conclusions
Our results indicate that the BFI-TS has a diagnostic accuracy higher than the other conventional sonographic signs. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination or open biopsy for accurate preoperative staging and individual therapy selection.
doi:10.1186/1471-2482-13-S2-S52
PMCID: PMC3851007  PMID: 24267705
37.  Cytological diagnosis of thyroid nodules in Hashimoto thyroiditis in elderly patients 
BMC Surgery  2013;13(Suppl 2):S41.
Background
Long standing Hashimoto Thyroiditis (HT) causes shrinking and atrophy of the thyroid, but may also lead to diffuse enlargement of the gland and/or formation of nodules. These nodules should be differentiated from papillary thyroid carcinoma (PTC) and primary thyroidal non-Hodgkin lymphoma (PTL), which are possible complications of HT, and require pre-surgical diagnoses and different treatments.
This study focuses on the role of fine-needle cytology (FNC) in the clinical surveillance and pre-surgical diagnosis of HT with diffuse and nodular enlargement of the gland in elderly patients.
Methods
Thirty-four elderly patients (≥ 65 yrs) with HT and diffuse or nodular enlargement of the thyroid underwent ultrasound (US)-guided FNC. Smears were routinely stained and evaluated; additional passes were used for flow cytometry (FC) assessment of lymphoid infiltrate in 6 cases.
Results
The cytological diagnosis was HT in 12 cases with prevalence of Hurtle cells in 2 cases, PTC in 1 case and PTL in 2 cases. FC assessed the reactive, non-lymphomatous nature of the lymphoid infiltrate in 5 cases and demonstrated light chain restriction, hence the lymphomatous nature of the lymphoid infiltrate in 2 cases of PTL.
Conclusions
FNC plays a key role in the clinical surveillance and pre-surgical diagnosis of diffuse enlargement and nodular presentation of HT in elderly patients. FNC can correctly diagnose HT, PTC and PTL indicating the need for surgery and its extension in suspicious or neoplastic cases, leaving other cases to the medical treatment and clinical surveillance.
doi:10.1186/1471-2482-13-S2-S41
PMCID: PMC3851014  PMID: 24266923
38.  Stress urinary incontinence: long-term results of laparoscopic Burch colposuspension 
BMC Surgery  2013;13(Suppl 2):S38.
Background
The open Burch colposuspension, first described in 1961 had been widely employed for the surgical treatment of women with stress urinary incontinence (SUI) caused by urethral hypermobility. We evaluated the long-term efficacy of laparoscopic Burch colposuspension (LBC) for SUI in women.
Methods
A randomized prospective trial was conducted from September 2010 to January 2013. The extraperitoneal laparoscopic Burch colposuspension was performed by an operator on 96 women, mean age was 54,3 ± 3,7 years all of whom suffered from SUI or mixed urinary incontinence. Patients completed a self-administered the Short Form-36 (SF-36), the Physical Component Summary (PCS) and Mental Component Summary (MCS), the Short Urinary Distress Inventory (SUDI) and Short Incontinence Impact Questionnaire (SIIQ). at both baseline and follow up(6 weeks, 6 months, 18 months postoperatively). The Genito-Urinary Treatment Satisfaction Scale (GUTSS) was used to assess satisfaction with surgery.
Results
After follow up was recorded an improvement of questionnaries scores. The general health score is improved after surgery (2,60 ± 1.02 versus 2,76 ± 1.06) with p = 0.09. The PCS baseline score is 46.29 ± 10.95 versus 49.54 ± 10.41 after treatment with p = 0.01, so there was a significant baseline to follow up improvement. The MCS improved also, infact baseline score is 42.19 ± 12.57 versus 42.70 ± 13.03 with p = 0.87. The SUDI baseline score is 50.22 ± 20.73 versus 23.92 ± 17.90, while SIIQ score is 49.98 ± 23.90 versus 31.40 ± 23.83 with p < 0.01. In both questionnaires there is an improvement. Satisfaction with treatment outcomes from the GUTSS at 6-month follow up is 29.5 ± 6.3 with p = 0.46.
Conclusion
The LBC has significant advantages, without any apparent compromise in short-term and long term outcomes.
doi:10.1186/1471-2482-13-S2-S38
PMCID: PMC3851039  PMID: 24268031
39.  Long term quality of life after laparoscopic antireflux surgery for the elderly 
BMC Surgery  2013;13(Suppl 2):S10.
Background
Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.
Methods
Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.
Results
Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).
There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).
Conclusions
In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.
doi:10.1186/1471-2482-13-S2-S10
PMCID: PMC3851040  PMID: 24267446
40.  Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly 
BMC Surgery  2013;13(Suppl 2):S9.
Background
Restorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis (UC). Debate exists concerning outcomes of IPAA in the elderly and literature data are scarce. We report our experience of IPAA in older population.
Methods
We gathered data on a prospective database of patients undergoing IPAA for UC over 70 years of age in our Unit from January 1990 through January 2010. Patients were compared with randomly selected younger controls on a 1:3 ratio. Patients underwent IPAA in 2 or 3 stages. Demographical data, disease characteristics, comorbidities, concomitant medications, peri-operative management, intra- and post-operative complications were analyzed. Function and quality of life were assessed by clinical visit and Inflammatory Bowel Disease Questionnaire 1 and 3 years after ileostomy takedown.
Results
Twenty-seven elderly patients underwent IPAA for UC in the study period; these were compared with 81 younger controls. The former had more comorbidities and higher ASA score. All patients underwent loop-ileostomy closure. There were no differences between groups concerning the rate of major complications, but elderly patients more frequently had nuisances due to stoma output. Younger patients experienced significantly more episodes of small bowel obstruction. No significant differences in bowel control and health-related quality of life was observed, except for an higher rate of elderly patients taking antidiarrhoeals at 1-year follow-up; this observation was not confirmed at 3-year follow-up. A minimal decrease in continence was observed, but this did not affect overall satisfaction.
Conclusions
IPAA can be safely offered to selected elderly UC patients who are strongly motivated and with no clinical disturbances of continence. In experienced hands no differences are likely to be expected concerning complications, quality of life and function. Results are stable with time and comparable to those of younger patients.
doi:10.1186/1471-2482-13-S2-S9
PMCID: PMC3851043  PMID: 24267006
Ileopouch-anal anastomosis; IPAA; ulcerative colitis; elderly patients; restorative proctocolectomy; quality of life
41.  How to utilize Ca2+ signals to rejuvenate the repairative phenotype of senescent endothelial progenitor cells in elderly patients affected by cardiovascular diseases: a useful therapeutic support of surgical approach? 
BMC Surgery  2013;13(Suppl 2):S46.
Endothelial dysfunction or loss is the early event that leads to a host of severe cardiovascular diseases, such as atherosclerosis, hypertension, brain stroke, myocardial infarction, and peripheral artery disease. Ageing is regarded among the most detrimental risk factor for vascular endothelium and predisposes the subject to atheroscleorosis and inflammatory states even in absence of traditional comorbid conditions. Standard treatment to restore blood perfusion through stenotic arteries are surgical or endovascular revascularization. Unfortunately, ageing patients are not the most amenable candidates for such interventions, due to high operative risk or unfavourable vascular involvement. It has recently been suggested that the transplantation of autologous bone marrow-derived endothelial progenitor cells (EPCs) might constitute an alternative and viable therapeutic option for these individuals. Albeit pre-clinical studies demonstrated the feasibility of EPC-based therapy to recapitulate the diseased vasculature of young and healthy animals, clinical studies provided less impressive results in old ischemic human patients. One hurdle associated to this kind of approach is the senescence of autologous EPCs, which are less abundant in peripheral blood and display a reduced pro-angiogenic activity. Conversely, umbilical cord blood (UCB)-derived EPCs are more suitable for cellular therapeutics due to their higher frequency and sensitivity to growth factors, such as vascular endothelial growth factor (VEGF). An increase in intracellular Ca2+ concentration is central to EPC activation by VEGF. We have recently demonstrated that the Ca2+ signalling machinery driving the oscillatory Ca2+ response to this important growth factor is different in UCB-derived EPCs as compared to their peripheral counterparts. In particular, we focussed on the so-called endothelial colony forming cells (ECFCs), which are the only EPC population belonging to the endothelial lineage and able to form capillary-like structures in vitro and stably integrate with host vasculature in vivo. The present review provides a brief description of how exploiting the Ca2+ toolkit of juvenile EPCs to restore the repairative phenotype of senescent EPCs to enhance their regenerative outcome in therapeutic settings.
doi:10.1186/1471-2482-13-S2-S46
PMCID: PMC3851045  PMID: 24267290
42.  Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience 
BMC Surgery  2013;13(Suppl 2):S24.
Background
Aim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables.
Methods
We described our standardized TAPP technique according with Stuttgart technique [1], and we evalutated our team's experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs).
Results
We retrospectively reviewed our Surgery Division's experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients.
Conclusions
According with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.
doi:10.1186/1471-2482-13-S2-S24
PMCID: PMC3851048  PMID: 24266979
43.  Role of conventional radiology and MRi defecography of pelvic floor hernias 
BMC Surgery  2013;13(Suppl 2):S53.
Background
Purpose of the study is to define the role of conventional radiology and MRI in the evaluation of pelvic floor hernias in female pelvic floor disorders.
Methods
A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms 'MR Defecography' and 'pelvic floor hernias'.
Results
The prevalence of pelvic floor hernias at conventional radiology was higher if compared with that at MRI. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on conventional radiology than on MRI, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at conventional radiology was significantly higher than that at MRI.
Conclusions
MRI shows lower sensitivity than conventional radiology in the detection of pelvic floor hernias development. The less-invasive MRI may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.
doi:10.1186/1471-2482-13-S2-S53
PMCID: PMC3851064  PMID: 24267789
MRI Defecography; Pelvic Floor; Hernias; Elderly patients
44.  Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions 
BMC Surgery  2013;13(Suppl 2):S50.
Background
Infectious complications are observed in 40-70% of all patients with severe acute pancreatitis. Infections are associated with a significant increase in mortality rates.
Methods
We evaluated the prevalence and characteristics of pancreatic and systemic infections in 46 patients with necrotizing pancreatitis submitted to surgical procedures during their hospital stay as well as the impact of such infectious complications on patient clinical outcome. Samples for microbiological cultures were taken at hospital admission from blood and bile and 2 days after invasive procedure from blood, drainage fluid, bile and necrotic tissues.
Results
74% patients with necrotizing pancreatitis had a localized or systemic infection. At admission, 15% of subjects had positive blood cultures whereas 13% had evidence of bacterial growth from bile cultures. Two days after the invasive procedures for removal of necrotic materials and fluids, blood cultures became positive in 30% of patients in spite of antibiotic prophylaxis and bile cultures resulted positive in 22% of cases. Furthermore, bacterial growth from drainage fluids was found in 30% and from homogenized necrotic material in 44% of cases. As refers to bacterial isolates, all patients had a monomicrobial infection. Carbapenems were the drugs with the best sensitivity profile.
Mortality rate was significantly (p < 0.05) higher among patients with infection (17%) than subjects without infection (8%). Within the infected group, those subjects with evidence of systemic infection (positive blood cultures) developed more complications and demonstrated a higher (p < 0.05) mortality rate (28%) than those who had only a localized infection (10%).
Conclusions
Infectious complications significantly increase mortality in patients with necrotizing pancreatitis. In addition, subjects with systemic infections developed more complications and demonstrated a higher mortality rate in comparison with those having a localized infection. In our study, the sensitivity pattern of the isolated microorganisms suggests to consider carbapenems as the best option for empirical treatment in patients with necrotizing pancreatitis who develop a clear-cut evidence of systemic or localized bacterial infection.
doi:10.1186/1471-2482-13-S2-S50
PMCID: PMC3851131  PMID: 24267612
45.  Pharmacological and dietary prevention for colorectal cancer 
BMC Surgery  2013;13(Suppl 2):S16.
Background
Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality. People at higher risk are those individuals with a family history of CRC and familial adenomatous polyposis. Prevention and screening are two milestones for this disease. The aim of this study is to evaluate the chemopreventive role of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin and cyclooxygenase 2 inhibitors, some micronutrients (folic acid, calcium, selenium, antioxidants) and probiotics.
Discussion
The studies on aspiring reported promising results, but it is debatable whether aspirin should be used as chemoprevention, because of its side effects and because of poor efficacy evident in subjects at high risk. Similar results were reported for other non-aspirin NSAIDs, such as sulindac and celecoxib, which the potential adverse effects limit their use. Selenium role in prevention of various types of cancer as well as in colon adenomas are often inconclusive or controversial. Several studies suggested that calcium may have a possible chemopreventive effect on colon adenomas and CRC, although contrasting results are reported for the latter. A recent meta-analysis including 13 randomized trial suggested that folic acid supplementation had not a chemiopreventive action on CRC. Several studies investigated the association between antioxidants, administered alone or in combination, and CRC risk, both among general and at risk population, but only few of them supported statistically significant results.
Conclusion
The results of this literature review showed an unclear role in CRC prevention of both pharmacological and dietary intervention. Despite several options are available to prevent colon cancer, it is challenging to identify a correct strategy to prevent CRC through pharmacological and dietary intervention due to the long latency of cancer promotion and development. Since some of the drugs investigated may have uncertain individual effects, it can be suggested to potentiate such effects by adding them together.
doi:10.1186/1471-2482-13-S2-S16
PMCID: PMC3851139  PMID: 24267792
46.  Day-surgery inguinal hernia repair in the elderly: single centre experience 
BMC Surgery  2013;13(Suppl 2):S28.
Background
Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients.
Methods
A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups.
Results
Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients.
Conclusions
Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.
doi:10.1186/1471-2482-13-S2-S28
PMCID: PMC3851140  PMID: 24267293
47.  Severe delayed postpolypectomy bleeding in elder patient with post-polycythemia myelofibrosis 
BMC Surgery  2013;13(Suppl 2):S18.
Background
The interest of the case lies in an unexpected delayed bleeding following an endoscopic procedure in a patient with post-polycythemia myelofibrosis. The case gives the opportunity to discuss the medical management and monitoring of patients with myeloproliferative disorders undergoing minimally invasive surgery interventions.
Case presentation
A 75 years old woman affected by post-polycythemia myelofibrosis underwent endoscopy polypectomy followed by a delayed major local bleeding. At the time of the endoscopy followed by bleeding, the platelet count was 837 × 109/L, haemoglobin 113 g/L, PCV 35,2% and WBC 20.22 × 106/L. No antithrombotic prophylaxis with low molecular weight heparin was used. Antiplatelet drug was withdraw seven days before endoscopy and restarted one week after the procedure. Polyp size was 11x19 mm and it was located on right side of the colon.
Fourteen days after procedure the patient developed a severe lower intestinal bleeding, which required RBC transfusion; the bleeding was in the site of polypectomy as demonstrated by arteriography; selective embolization of the three branches of the ileo-colic artery resolve the haemorrhage.
Conclusion
There are some patients in whom current guidelines do not apply and our case stress the importance of myeloproliferative neoplasms as a risk factor for complications of endoscopic polypectomy. The delayed haemorrhage we observed suggest to strictly control the patient for a period longer than only one week also in case of antithrombotic treatment with antiplatelet drugs.
doi:10.1186/1471-2482-13-S2-S18
PMCID: PMC3851144  PMID: 24267952
48.  Pulmonary sequestration presented as massive left hemothorax and associated with primary lung sarcoma 
BMC Surgery  2013;13(Suppl 2):S34.
Pulmonary sequestration is an uncommon disease, accounting for only approximately 1.5% of all congenital pulmonary malformations. In most cases, the diagnosis is a result of accidental radiological findings; it is rarely accompanied by clinical symptoms, and is more commonly associated with other congenital malformations. Herein, we reported a case of pulmonary sequestration presented as massive left hemothorax and associated with primary lung sarcoma. A pneumonectomy via thoracotomy was attended with complete resection of sequestration and of sarcoma. The postoperative course was unremarkable, and the patient was discharged on postoperative day 11.
doi:10.1186/1471-2482-13-S2-S34
PMCID: PMC3851145  PMID: 24267748
Pulmonary Sequestration; hemithorax; primary sarcoma
49.  Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue 
BMC Surgery  2013;13(Suppl 2):S8.
Background
Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.
Methods
Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.
Results
Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.
Conclusions
Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.
doi:10.1186/1471-2482-13-S2-S8
PMCID: PMC3851152  PMID: 24266959
50.  TEM in the treatment of recurrent rectal cancer in elderly 
BMC Surgery  2013;13(Suppl 2):S56.
Introduction
Transanal microscopic surgery is an important application of minimally invasive surgery of rectum, allowing realization of complex transanal intervention.
Patients and Methods
During the period between January 2002 and December 2010, seven patients, five men and two women, average age 75 years, with early rectal cancer recurrence were selected for this type of surgical palliative procedure. The selection of the patients is made by: transrectal ultrasonografy, colonoscopy and abdominal ultrasonografy, to rule out liver metastases, CT with and without enema, PET CT. Follow-up is approximately 12-30 months.
Results
The pathologic staging confirms the complete excision of recurrences. Then patients are referred for more complementary therapies.
Discussion
The significance of conservative treatment for local recurrence of rectum adenocarcinoma is still controversial because the recurrence is an expression of tumor spread not controlled by oncological surgical and radio/chemo therapy.
Conclusion
In selected subjects such as the elderly, based on equal oncological treatment, the reduction of surgical trauma, preservation of anatomical integrity and resolution of symptoms are important results.
doi:10.1186/1471-2482-13-S2-S56
PMCID: PMC3851153  PMID: 24267977
Recurrence of Rectal; Cancer; Mininvasive Surgery; Palliative Surgery

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