Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up.

BACKGROUND: Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up. METHODS: This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years. RESULTS: A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05). CONCLUSIONS: Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.

A rare case of jejunal Vanek's tumor causing intussusception in an adult: a case report and comprehensive literature overview.

Inflammatory fibroid polyp, or Vanek's tumor, is an uncommon benign small bowel tumor and a rare cause of intussusception in adults. This case involves a 62-year-old man with persistent abdominal pain, diagnosed with jejunoileal intussusception. A 4 cm inflammatory fibroid polyp was discovered during surgery, leading to distal jejunal resection. Despite the rarity of adult intussusceptions, they should be considered in abdominal pain diagnoses. The optimal management approach, whether en bloc resection or initial reduction with limited resection, remains debated.

Acute Esophageal Necrosis as a Rare Complication of Metabolic Acidosis in a Diabetic Patient: A Case Report.

BACKGROUND Acute esophageal necrosis, or Gurvits syndrome, is a rare clinical process often secondary to a systemic low-flow state. It can be caused by several medical conditions, and it is thought to arise from a combination of impaired mucosal barrier and chemical and ischemic insults to the esophagus. Acute esophageal necrosis usually presents with severe complications due to delayed diagnosis and only rarely has surgical indications. We present a case of Gurvits syndrome, presumably triggered by metabolic acidosis in a diabetic patient. CASE REPORT A 61-year-old man with history of hypertension and type 2 diabetes mellitus treated with metformin, canagliflozin, glimepiride, and pioglitazone came to our attention with persistent vomiting, odynophagia, chest pain after each meal, and progressive weight loss. Arterial blood analysis showed mild metabolic acidosis, while the first esophagogastroduodenoscopy performed revealed a circumferential black appearance of the esophageal mucosa, as in concentric necrosis of the distal esophagus with possible fungal superinfection. Brushing cytology confirmed the infection by Candida spp. and the patient was treated with intravenous fluconazole. The second esophagogastroduodenoscopy, performed after 2 weeks, showed almost complete healing of the esophageal mucosa; in this case, biopsy confirmed mucosal ischemia and necrosis, without showing deep impairment of the mucosa by fungal agents. CONCLUSIONS Due to its high lethality, often caused by the underlying medical diseases, acute esophageal disease should be considered in the differential diagnosis of digestive symptoms, even without upper gastrointestinal bleeding. Prompt diagnosis and treatment of contextual collateral conditions can help clinicians to avoid the worst outcomes of the disease. Among the causative factors of metabolic acidosis leading to esophageal necrosis we recognized metformin and dapagliflozin.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care.

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

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.

The Berne-Donovan technique for diverticulization of a severe lateral non-traumatic duodenal fistula.

BACKGROUND: The duodenal «diverticulization¼ is a surgical technique described by Berne and colleagues in 1968 for the treatment of combined duodenal pancreatic injuries. It consisted of closure of the duodenal injury by suture and tube duodenostomy, gastric antrectomy with end-to-side isoperistaltic Billroth II gastrojejunostomy, and abdominal drainage. As evidenced from the literature in few reports, this technique has also been adopted for lateral duodenal lacerations in non traumatic conditions. Most biliary disease may be responsible for duodenal injury. CASE PRESENTATION: Herein, we describe the application of this emergency technique for the treatment of a wide lateral duodenal laceration discovered intra-operatively during laparoscopic cholecystectomy for acute cholecystitis. A comprehensive critical review of the different surgical methods proposed for duodenal protection in case of severe duodenal lesions has been performed and discussed. CONCLUSION: Duodenal injuries represent a challenging condition, especially for surgeons with limited experience in this field. The key-message of this report is to consider emergency surgical techniques in difficult unexpected intra-operative situations which may occur during routine surgical practice. KEY WORDS: Duodenal diverticulization, Duodenal fistula, Laparoscopic cholecystectomy, Surgical repair.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

OBJECTIVE: To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS: A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS: There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS: This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Impact of COVID-19 on surgical activities and personnel: lessons for the future.

BACKGROUND: COVID-19 pandemic has impacted professional, economic and social activities. In the surgical field, it has brought changes to operating activities, the organization of workforces, the protection measures for patients and personnel against possible intraoperative transmissions as well as training young surgeons. This study intends to assess the extent of this impact in our institution. METHODS: The patients operated on in nine Operating Units (OUs) in the period February 1 - March 31, 2020, with follow-ups on April 30, 2020, were evaluated both retrospectively and prospectively. Organizational, clinical and impact parameters on staff were evaluated. RESULTS: Of the 833 consecutive admitted patients, 742 were operated on, 705 of whom were recruited for the study. Compared to the same period in 2019 there was a decrease in the number of operations (742 compared to 1187), similar use of intensive care unit (ICU), a diagnostic activity only for symptomatic patients, heterogeneity in organizational behaviors, an impact on staff who highlighted concerns about getting sick or passing the infection on to others (87.64%) or their family members (75.14%). CONCLUSIONS: The present study made it possible to detect the need to make significant changes in the clinical, organizational and teaching fields, for which some operational proposals are suggested.

COVID-19 inpatients with gastrointestinal onset: sex and care needs' differences in the district of Ferrara, Italy.

BACKGROUND: COVID-19 is characterized by interstitial pneumonia, but a presentation of the disease with digestive symptoms only may occur. This work was aimed at evaluating: (1) the prevalence of presentation with digestive symptoms only in our cohort of COVID-19 inpatients; (2) differences between patients with and without gastrointestinal onset; (3) differences among males and females with gastrointestinal presentation; (4) outcomes of the groups of subjects with and without gastrointestinal onset. METHOD: We retrospectively divided the patients hospitalized with COVID-19 into two groups: (1) the one with digestive symptoms (DSG) and (2) the other without digestive symptoms (NDSG). We compared the subjects of DSG with those of NDSG and males with females in the DSG group only, in terms of demographics (age, sex), inflammation and organ damage indexes, length of stay, in-hospital and 100-day mortality. RESULTS: The prevalence of gastrointestinal symptoms at presentation was 12.5%. The DSG group showed a prevalence of females, and these tended to a shorter hospital stay; DSG patients were younger and with a higher load of comorbidities, but no differences concerning inflammation and organ damage indexes, need for intensification of care, in-hospital and 100-day mortality were detected. Among DSG patients, males were younger than females, more comorbid, with higher serum CRP and showed a longer length of hospital stay. Survival functions of DSG patients, in general, are more favourable than those of NDSG if adjusted for sex, age and comorbidities. CONCLUSIONS: (1) The prevalence of gastrointestinal presentation among hospitalized COVID-19 patients was 12.5%; (2) DSG patients were on average younger, more comorbid and with a prevalence of females, with a shorter hospital stay; (3) in the DSG group, males had a higher Charlson Comorbidity Score and needed a longer hospital stay; (4) DSG subjects seem to survive longer than those of the NDSG group.

Laparoscopic versus Open Transverse-Incision Approach for Right Hemicolectomy: A Systematic Review and Meta-Analysis.

Background and Objectives: There is general agreement on the benefits of laparoscopy for treatment of rectal and left colon cancers, whereas findings regarding the comparison of laparoscopic and open right colonic resections are discordant. The aim of this systematic review and meta-analysis was to assess the outcomes and advantages of laparoscopic versus transverse-incision open surgery for management of right colon cancer. Materials and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Comparative studies evaluating the results of laparoscopic and transverse-incision open right hemicolectomies were analyzed. The measured outcomes were mean operative time, time to feeding, duration of hospital stay, and number of lymph nodes harvested. Results: A total of 5 studies including 318 patients met the inclusion criteria. Meta-analysis revealed no differences in time to resume oral feeding, hospital stay, and number of lymph nodes harvested in between groups, but mean length of surgery was significantly longer in the laparoscopic group. Conclusion: These data confirm that the preferred approach to right hemicolectomy is yet unclear. Laparoscopy has a longer operative time than transverse-incision open surgery, and no significant short-term benefits were observed for the studied parameters. Well-designed randomized control trials (RCTs) might help to identify the differences between these two techniques for the surgical treatment of right colon cancer.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial.

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

Laparoscopic versus open transverse-incision right hemicolectomy: a retrospective comparison study.

BACKGROUND: The optimal surgical approach to right colon cancer is still under debate. The aim of the present study was to compare the short- and long-term outcomes of laparoscopic and transverse-incision open approaches to right hemicolectomy for colon cancer. METHODS: Data on 99 adult patients with right-side colon cancer undergoing either laparoscopic or open transverse-incision right hemicolectomy at two different university hospitals, between January 2013 and December 2016, were retrospectively reviewed. Data concerning patients' characteristics, operative details and post-operative recovery were retrieved from prospective databases and analysed. RESULTS: Forty-nine subjects were operated on laparoscopically, while 50 through an open transverse incision. Operating time was significantly longer in the laparoscopic group compared with the open group (182 versus 105 min; P < 0.01). Patients treated laparoscopically had a shorter time to first bowel movement, while time to resume a normal diet and post-operative length of hospital stay were comparable in between groups. The median number of lymph nodes harvested was higher in the laparoscopic group (25.6 versus 18.6; P < 0.01), but no significant difference in overall survival between groups was detected. At long-term follow-up, the incidence of incisional hernia was higher in the laparoscopic group as compared to the open group (24.5% versus 0%; P = 0.0002). CONCLUSION: Our results show that laparoscopic right hemicolectomy when compared to the transverse-incision open procedure may guarantee the same oncological radicality, but short-term functional benefits are still unclear. Randomized control studies are warranted to better clarify the comparison of these two approaches for right-sided colon cancers.

A rare case of ileo-ileal intussusception due to a bleeding lipomatous mass treated by laparoscopic ileal resection.

INTRODUCTION: Adult intussusception is a rare cause of bowel obstruction with atypical presentation. It can be associated with primary or secondary intestinal tumors and, rarely, with lipomatous masses. CASE REPORT: We report the case of a 69-year old man presenting with a history of gastrointestinal bleeding and anemia. Upper and lower endoscopies were negative for bleeding. On abdominal contrast enhanced computerized tomography (CT) scan, a trans-omental hernia in the right lower abdominal quadrant was diagnosed with no active bleeding or evidence of tumor. On exploratory laparoscopy we detected an ileo-ileal intussusception caused by a submucosal mass in the distal ileum, which was reduced and we then performed a segmental resection of the involved small bowel tract. The patient fully recovered by postoperative day 3 when he was discharged home. Final pathology confirmed an ileal lipoma. CONCLUSION: Ileal intussusception caused by lipoma is a rare condition, which can be diagnosed with endoscopy, barium enema, and abdominal ultrasound or CT scanning, but preoperative diagnosis may be difficult. The treatment of choice is the reduction of the intussusception and the resection (laparoscopic or open) of the involved tract. KEY WORDS: Intussusception, Lipoma, Ileum, Laparoscopy, Bleeding.

Adrenal cavernous hemangioma: a case report.

BACKGROUND: Adrenal cavernous hemangiomas are very rare benign tumors that usually present as incidental findings on abdominal imaging. Preoperative differential diagnosis from other benign or malignant adrenal neoplasms may be challenging. CASE PRESENTATION: A 70-year old man was referred for an 8-cm abdominal mass incidentally discovered on a contrast-enhanced computed tomography (CT) performed to investigate a pulmonary nodule. Biochemical tests ruled out any endocrine dysfunction and iodine 123 metaiodobenzylguanidine whole body scintiscan single-photon emission CT excluded a pheocromocitoma. Findings on magnetic resonance imaging were non-specific and the patient was elected for a left adrenalectomy. Histopathological diagnosis revealed a cavernous hemangioma. A portion of the resected tissue was tested for drug sensitivity to mitotane, doxorubicin, and sunitinib. CONCLUSIONS: Adrenal hemangioma is a rare disease but should be included in the differential diagnosis of adrenal tumors. The surgical resection is generally required to exclude malignant disease, resolve pressure-related symptoms, and prevent retroperitoneal hemorrhage. Although specific features in diagnostic imaging are often lacking, if the diagnosis is established preoperatively a laparoscopic adrenalectomy can be performed due to the benign nature of the lesion. Doxorubicin and sunitinib were both capable of reducing primary culture cell viability, this suggest that similar drugs may be useful in the medical treatment of adrenal hemangiomas.

Upregulation of the alternative splicing factor NOVA2 in colorectal cancer vasculature.

BACKGROUND: Tumor-specific isoforms generated by alternative splicing (AS) are demonstrated to contribute to tumor progression and can represent potential biomarkers. NOVA2 is an AS factor that in physiological conditions regulates endothelial cells' (ECs) polarity and vessel lumen maturation, likely by mediating AS of apical-basal polarity regulators. However, NOVA2 expression in tumor ECs and its regulation have never been investigated. METHODS: To elucidate this, 40 colorectal cancer patients were enrolled and NOVA2 expression was investigated by immunohistochemistry in samples bearing both the normal mucosa and the tumor tissue. RESULTS: NOVA2 was found expressed in ECs of tumor vasculature and, importantly, it was upregulated in tumor ECs with respect to normal mucosa ECs in all cases (P<0.001). The same samples analyzed by immunohistochemistry for the expression HIF1α, a marker of hypoxia, showed a positive and significant association with NOVA2 levels (P=0.045). Of note, NOVA2 was upregulated by hypoxia also in an in vitro ECs model. CONCLUSION: Our results provide, for the first time, evidence of NOVA2 expression and upregulation in tumor ECs and highlight hypoxia as a potential regulatory factor. These findings open a completely new perspective to study tumor vasculature and to uncover NOVA2 as a potential source of biomarkers and therapeutic targets based on AS isoforms.

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control.

BACKGROUND: The enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. MATERIALS AND METHODS: A prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013-2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010-2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. RESULTS: Hospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). CONCLUSIONS: Implementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.

Laparoscopic treatment of colo-colic intussusception secondary to a lipomatous polyp.

INTRODUCTION: Colo-colic intussusception is extremely rare in adults and few cases have been described secondary to a lypomatous polyp. CASE REPORT: We present the case of a 50-year old man with chronic abdominal pain who was diagnosed a colo-colic intussusception secondary to a lipoma of the left colon. The patient underwent laparoscopic resection of the splenic flexure without reduction, which occurred spontaneously after induction of the pneumoperitoneum, and final histology confirmed a submucosal lipoma with no evidence of malignancy. CONCLUSION: The traditional treatment of choice for adult intussusception is bowel resection without reduction. More recently, however, preoperative reduction of the invaginated bowel segment has been reconsidered in order to: 1) avoid emergency surgery, 2) allow radical surgery for cancer, and 3) reduce the extent of the intestinal resection. To the best of our knowledge, this is the first case of adult colonic intussusception secondary to a lipoma treated by laparoscopy. KEY WORDS: Colon, Intussusception, Laparoscopy, Lipoma.

The effect of an Enhanced Recovery Program in elective retroperitoneal abdominal aortic aneurysm repair.

OBJECTIVE: Enhanced Recovery Programs (ERPs) have been introduced to accelerate postoperative recovery and are mainly focused on decreasing the surgical stress response. Limited data are available regarding the implementation of ERPs in patients who undergo abdominal aortic aneurysm (AAA) repair using the retroperitoneal approach. The aims of this study were: (1) to evaluate the implementation of an ERP in patients who underwent elective retroperitoneal AAA repair; and (2) to define independent predictors of prolonged hospital length of stay (LOS) in these patients. METHODS: This was a retrospective cohort study on 221 patients who underwent elective AAA repair via a retroperitoneal approach from 2005 through 2013 at an Italian university hospital. Patients who received surgery from 2008 through 2013 and enrolled in an ERP (n = 130) were compared with those who received surgery from 2005 through 2007 and managed with traditional perioperative care (n = 91). RESULTS: Patient characteristics were comparable between groups. Intensive care unit admissions were prevalent among patients who received traditional care vs patients in the ERP (P < .01). ERP patients had fewer major (P < .01) and minor (P = .019) complications, and mortality was similar between groups. Complete functional recovery was achieved earlier in ERP patients vs controls (P < .01). Patients in the ERP group left the hospital earlier than controls (P < .01). No readmission ≤30 days were reported in the ERP group. Age ≥65 years and being in a conventional care protocol were found to be independent predictors of prolonged hospital LOS. CONCLUSIONS: The implementation of an ERP after elective AAA repair using a retroperitoneal approach reduced postoperative intensive care unit admission, accelerated functional recovery, and decreased morbidity and LOS with no readmission ≤30 days. Age ≥65 years and conventional perioperative care were the only independent predictors of prolonged 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.