Total robotic pancreaticoduodenectomy: a systematic review of the literature.

BACKGROUND: Pancreaticoduodenectomy (PD) is a complex operation with high perioperative morbidity and mortality, even in the highest volume centers. Since the development of the robotic platform, the number of reports on robotic-assisted pancreatic surgery has been on the rise. This article reviews the current state of completely robotic PD. MATERIALS AND METHODS: A systematic literature search was performed including studies published between January 2000 and July 2016 reporting PDs in which all procedural steps (dissection, resection and reconstruction) were performed robotically. RESULTS: Thirteen studies met the inclusion criteria, including a total of 738 patients. Data regarding perioperative outcomes such as operative time, blood loss, mortality, morbidity, conversion and oncologic outcomes were analyzed. No major differences were observed in mortality, morbidity and oncologic parameters, between robotic and non-robotic approaches. However, operative time was longer in robotic PD, whereas the estimated blood loss was lower. The conversion rate to laparotomy was 6.5-7.8%. CONCLUSIONS: Robotic PD is feasible and safe in high-volume institutions, where surgeons are experienced and medical staff are appropriately trained. Randomized controlled trials are required to further investigate outcomes of robotic PD. Additionally, cost analysis and data on long-term oncologic outcomes are needed to evaluate cost-effectiveness of the robotic approach in comparison with the open technique.

Biological mesh for abdominal wall hernia synthetic mesh multidrug-resistant Pseudomonas aeruginosa infection: report of a case.

The use of biological mesh for the treatment of synthetic mesh-related infections in patients who undergo ventral hernia repair has been considered over the past few years. Removal of the infected synthetic mesh, which may be required in such cases, can result in recurring herniation. Biological implants have thus been recently used for the reconstruction of the existing defect. We herein present the case of a patient who developed multidrug-resistant Pseudomonas aeruginosa synthetic mesh infection following hernia repair, which was managed by the removal of the material and the application of a biological mesh in the contaminated area.

Biological mesh in hernia repair, abdominal wall defects, and reconstruction and treatment of pelvic organ prolapse: a review of the clinical evidence.

The use of biological meshes seems to be an innovation that influences all surgical fields. The existing evidence indicates that biological meshes cannot only be applied on the area of hernia repair, but also on cases of abdominal reconstruction and pelvic organ prolapse treatment, especially in the presence of contaminated or potentially contaminated surgical fields. Low risks of graft rejection, complications, and infection seem to be the main advantages of biological meshes in comparison with the synthetic nonabsorbable ones. Nevertheless, the elevated costs suggest that biological mesh implantation should be evaluated in correlation to the needs of each clinical case.

Operative treatment of athletic pubalgia in competitive athletes: a retrospective study.

BACKGROUND: Athletic pubalgia is an obscure sport injury, presenting mainly with groin pain during twisting movements. The present 15 year study reports outcomes, intraoperative findings and complications of the endoscopic surgical treatment in competitive athletes. METHODS: All competitive athletes, from 2004 to 2018, suffering from athletic pubalgia, treated with laparoscopic Total Extra-Peritoneal technique, at the Department of General, Laparoscopic, Oncologic and Robotic Surgery of the Athens Medical Center were included in this retrospective cohort. Postoperative pain, complications, return to previous training routine and patients' satisfaction were evaluated. RESULTS: A total of 130 patients (115; 88.5% males and 15; 11.5% females) with a mean age of 26.7±7.5 years were evaluated. Preoperatively, mean numeric scale pain was found to be 7.7±1.7. Three days postoperatively, the mean numeric pain scale was 3.4±1.5, showing 55.8% decrease. The mean time for return to sports activity was found to be 6.27±3.02 weeks. Regarding complications, six patients (4.6%) had slight numbness at the groin area during the first 6 postoperative months and one patient (0.8%) suffered from a postoperative hematoma. No recurrence was observed. At the final follow-up (mean 76.58±46.5 months), a total of 97 (74.7%) patients were very satisfied, 31 (23.8%) satisfied and two (1.5%) not satisfied with the outcome. CONCLUSIONS: Laparoscopic operative treatment in competitive athletes suffering from athletic pubalgia seems to offer rapid recovery, rapid return to sports, as well as very low complications rate and no recurrence.

Robotic resection of a giant retroperitoneal leiomyosarcoma: A case report.

The management of abdominal leiomyosarcoma is challenging. Surgical excision is considered the only effective treatment; however, this is associated with considerable morbidity. Robotic surgery has emerged during the past decades and has enhanced the general surgery armamentarium, allowing surgeons to carry out demanding operations in a safe manner. The surgical resection of retroperitoneal leiomyosarcoma (RPLM) can be associated with significant morbidity, which is primarily due to the origin or the close proximity of the tumor with important vascular structures, including the inferior vena cava and tributaries, the duodenum and the ureter. The present case describes the first case of robotic resection of RPLM in a high-volume robotic center. In the present case, a large RPLM was safely removed with respect to oncological principles with the use of the Da Vinci platform.

Use of a biological mesh for the treatment of perineal fistula following radical colorectal resection.

Patients with postradiation therapy for malignancies and/or extensive colorectal surgery are prone to the development of enteroperineal fistulas. Application of biological meshes may prove beneficial in treating complicated enteroperineal fistulas as they provide a stable ground for closing pelvic defects even in contaminated fields.

Ghrelin and Obesity: Identifying Gaps and Dispelling Myths. A Reappraisal.

The etiology of obesity is complex. Environmental and genetic causes have been implicated in the development of this disease. Ghrelin is a hormone known to stimulate appetite. There are numerous possible actions through which ghrelin exerts its effect in the body: a) Overproduction of ghrelin, b) reduced ghrelin following meals, and c) increased receptor sensitivity to ghrelin action. Sleeve gastrectomy, a bariatric procedure, leads to reduction of ghrelin levels and subsequently to weight loss. However, there are many limitations to measurement of the fasting plasma level of the active form of ghrelin. The establishment of the exact correlation between ghrelin, appetite and obesity could be vital for the fight against obesity.

Transanal evisceration of the small bowel a rare complication of rectal prolapse.

INTRODUCTION: Transanal evisceration of small bowel is an extremely rare surgical emergency. Of the nearly 70 cases reported in the literature, rectal prolapse is the predisposing factor that has been most frequently related to this pathology. PRESENTATION OF CASE: We report a 78-year-old female with history of chronic rectal prolapse who presented in our emergency department with evisceration of small intestinal loops through the anus. In surgery after complete reduction of the eviscerated bowel into the peritoneal cavity, almost 20cm of the terminal ileum up to the ileocecal valve were necrotic and therefore a right hemicolectomy with primary anastomosis was performed. Additionally a 2cm craniocaudally tear was revealed in the antimesenteric border of the upper rectum and a Hartman procedure was also performed. The patient was discharged after 10 days. DISCUSSION: Early recognition and timely surgical intervention offers the best prognosis, avoiding a fatal conclusion or an extensive intestinal resection.

The current status of robotic vascular surgery in the abdominal cavity.

BACKGROUND: Robotically assisted procedures have emerged within vascular surgery as an alternative to open procedures for the treatment of arterial aneurysms and arterial occlusive diseases. METHODS: A thorough literature search was conducted to retrieve studies reporting the use of robotic systems for the management of aneurysms and arterial obstructive diseases. RESULTS: Eleven studies included data about abdominal aortic aneurysms (AAA) or aortoiliac occlusive disease (AIOD) related conditions. Among 260 patients, the reported aortic clamping time in AAA repairs ranged from 39 to 113 minutes, whilst the time needed for the anastomosis varied between 21.5-43 minutes for AAA and AIOD treatment. The conversion rates also ranged between 0-2% respectively, whilst patient hospital stay varied between 1.5 to 12.2 days. CONCLUSION: Despite the relatively small number of relevant studies, the results are promising. However randomised control trials will help elucidate further the potential superiority of robotic mediated procedures in vascular surgery.

Type IV paraesophageal hernia as a cause of ileus: Report of a case.

INTRODUCTION: Type IV paraesophageal hernias (PEHs) have been rarely reported in the literature. Transverse colon is the most common viscus to herniate in this category. PRESENTATION OF CASE: Herein we present a case with an emergent admission of a 66 year old man with type IV PEH with small intestine into the hernia sac. DISCUSSION: The diagnosis of PEHs can be challenging due to their extremely low incidence and the non-specific symptoms and can be easily missed from the initial differential diagnosis. CONCLUSION: In this case, the hernia was diagnosed early and managed successfully with an immediate laparotomy.

A 'giant' paraganglioma in the testis.

UNLABELLED: Until now, less than ten cases of extra-adrenal chromaffin cell tumors have been reported to be localized to the spermatic cord area. All published studies report benign tumors with a diameter <2-3 cm and no invasion of the testis. In this article, we present one case of a giant malignant paraganglioma in the testis of a patient who had initially been operated for a giant mass in the scrotum. The mass developed in approximately 4 months. This is the first study reporting the following findings: i) paraganglioma was found exclusively in the testis, invading the testicle and not the spermatic cord, ii) it was malignant with lung metastasis, and iii) its size was 17.5 cm×10 cm×9.5 cm. We present the first - giant - malignant paraganglioma. Moreover, it is the first case report of a paraganglioma in the testis. LEARNING POINTS: This is the first study reporting the following findings:Paraganglioma found exclusively in the testis, invading the testicle and not the spermatic cord.It is malignant with lung metastasis.It is of the size 17.5 cm×10 cm×9.5 cm.

Total invasion of the pancreatic gland by a rare aggressive IPMN: Report of a case.

INTRODUCTION: The intraductal papillary mucinous neoplasms (IPMNs) are increasingly diagnosed entities with high potential of malignancy and significant recurrence rates. PRESENTATION OF CASE: In this case report a rare mixed IPMN with full invasion of the pancreatic ducts was identified. DISCUSSION: Difficulties in determining the grade of pancreatic duct involvement make the surgical management tough. CONCLUSION: In multifocal IPMNs the management of the patients is even more challenging. In this case the patient was treated successfully with total pancreatectomy.

Safety of hepatitis B, pneumococcal polysaccharide and meningococcal polysaccharide vaccines in pregnancy: a systematic review.

Immunization during pregnancy has the potential to protect the mother and the newborn from preventable diseases. Current recommendations suggest that inactivated vaccines might be considered during pregnancy when the benefits outweigh the risks. In this review, we aimed to evaluate the safety of hepatitis B (HB) vaccine, pneumococcal polysaccharide vaccine (PPSV) and meningococcal polysaccharide vaccine (MPSV) administration during pregnancy by systematically reviewing the available evidence in PubMed and Scopus databases, as well as postmarketing surveillance data (including the Vaccine Adverse Event Reporting System [VAERS] database). A total of 18 studies were eligible for inclusion in the review. Six studies provided data on HB vaccine, six on PPSV and three on MPSV; three additional studies compared PPSV with MPSV. Additionally, 91 reports on vaccinations of pregnant women were identified from postmarketing surveillance data (88 on HB vaccine, 2 on PPSV, 1 on MPSV). The most common complaints were local reactions, including tenderness and swelling. Overall, immunization during pregnancy did not seem to be associated with a teratogenic effect on the fetus, preterm labour or spontaneous abortion. However, the lack of randomized, placebo-controlled trials, or even large cohort studies, in addition to the inherent limitations of the reviewed observational studies with small statistical power, precluded safe conclusions. Large, prospective, population-based cohort studies are needed to elucidate this issue.

Efficacy and safety of telavancin in clinical trials: a systematic review and meta-analysis.

INTRODUCTION: The epidemiology and antibiotic resistance of Staphylococcus aureus have evolved, underscoring the need for novel antibiotics, particularly against methicillin-resistant S. aureus (MRSA). Telavancin is a bactericidal lipoglycopeptide with potent activity against Gram-positive pathogens. OBJECTIVE: To systematically review and synthesize the available evidence from randomized controlled trials (RCTs) evaluating telavancin in the treatment of patients with infections due to Gram-positive organisms with the methodology of meta-analysis. RESULTS: Six RCTs comparing telavancin with vancomycin were included; 4 (2229 patients) referred to complicated skin and soft tissue infections (cSSTIs) and 2 (1503 patients) to hospital-acquired pneumonia (HAP). Regarding cSSTIs, telavancin and vancomycin showed comparable efficacy in clinically evaluable patients (odds ratio [OR] =1.10 [95% confidence intervals: 0.82-1.48]). Among patients with MRSA infection, telavancin showed higher eradication rates (OR=1.71 [1.08-2.70]) and a trend towards better clinical response (OR=1.55 [0.93-2.58]). Regarding HAP, telavancin was non-inferior to vancomycin in terms of clinical response in two Phase III RCTs; mortality rates for the pooled trials were comparable with telavancin (20%) and vancomycin (18.6%). Pooled data from cSSTIs and HAP studies on telavancin 10 mg/kg indicated higher rates of serum creatinine increases (OR=2.22 [1.38-3.57]), serious adverse events (OR=1.53 [1.05-2.24]), and adverse event-related withdrawals (OR=1.49 [1.14-1.95]) among telavancin recipients. CONCLUSION: Telavancin might be an alternative to vancomycin in cases of difficult-to-treat MRSA infections. The potent antistaphylococcal activity of telavancin should be weighted against the potential for nephrotoxicity.

The pleiotropic effects of statins and omega-3 fatty acids against sepsis: a new perspective.

The available therapeutic options for sepsis are restricted by their effectiveness and high cost. Emerging preliminary data suggest that statins and omega-3 fatty acids (OM3FA) may be associated with improved outcomes in terms of prevention and treatment of sepsis. We sought to review the current evidence on the effectiveness of their combined administration against sepsis, by carrying out a review of PubMed and Scopus databases for relevant studies, without imposing language or time restrictions. No clinical studies were identified regarding the effect of the combination treatment with statins and OM3FA on sepsis in terms of prevention or treatment. However, there is experimental evidence that both statins and OM3FA inhibit the inflammatory process at different levels, but also enhance inhibition at those levels that are common. There are also preliminary data supporting the beneficial effect of this combination on platelet function and other haemostatic mechanisms. Appropriately designed and powered clinical trials are warranted to investigate the effectiveness and safety of the combined administration of statins and OM3FA for the prevention and treatment of sepsis.

The role of infection in carotid plaque pathogenesis and stability: the clinical evidence.

INTRODUCTION: Chlamydia pneumoniae was the first pathogen linked with carotid atherosclerotic changes and plaque rupture. Currently, other common pathogens are also under investigation as potential contributors. METHODS: A systematic review of PubMed and Scopus databases was performed. Studies evaluating the infectious burden between symptomatic and asymptomatic patients with carotid plaque disease (CPD) were included. Furthermore, trials referring to common infectious agents (other than C. pneumoniae) incriminated for contribution in CPD were analyzed separately. RESULTS: Forty four studies were identified; 6 investigated the connection of infection with the plaque destabilization, 3 of which reported a significant association between infection and symptoms. Studies retrieved for the investigation of agents other than C. pneumoniae were: 18 about viruses, 16 about other bacteria and 4 examining both. Significant association or high detection rates of agents' genome or specific antibodies with CPD characteristics (intima media thickness values > 1 mm or symptoms) were found in a number of studies: 3 for HCV, 2 for CMV and 1 for enterovirus, EBV, HBV, and HIV. Moreover 4 studies about dental pathogens (i.e. Porpyromonas gingivalis), 5 about H. Pylori strains and 1 about Borrelia burgdorferi were identified supporting a positive association. CONCLUSION: There is considerable evidence supporting the contribution of other commonly encountered pathogens in the pathogenesis and rupture of the carotid plaque. Research in this direction should not be abandoned and further studies are necessary to elucidate the exact role of common infections in the pathogenesis and development of CPD and how this can be translated into novel pharmacological approaches for prevention and treatment.