Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair.

BACKGROUND: Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months. MATERIAL: A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation. RESULTS: Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542). CONCLUSION: The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

Aberrant left hepatic arteries arising from left gastric arteries and their clinical importance.

BACKGROUND: The Aberrant Left Hepatic Artery (ALHA) is replaced when it does not originate from the hepatic artery proper and it is the only supply to that part of the liver, while an accessory artery coexists with a normal artery. The aim of this systematic review is to evaluate the incidence of ALHAs including the one arising from the Left Gastric Artery, also named Hyrtl's artery. METHODS: A literature search in PubMed, SCOPUS, WOS and Google Scholar was performed. The risk of bias was assessed by means of the AQUA tool. The main outcome was the prevalence of ALHA. Secondary outcomes were the prevalence of the accessory and replaced left hepatic arteries. A subgroup analysis was conducted by geographic region and type of evaluation. RESULTS: This review included 57 studies, with a total of 19,284 patients. The majority of the studies involved the use of radiological techniques -especially Angio-CT-and were performed in Asia. The overall risk of bias was moderate. The overall prevalence of the ALHA was 13.52%; the overall prevalence was 8.26% for the Replaced ALHA and 5.55% for the Accessory ALHA. In the 18 studies that employed Michels' classification, Type II had the lowest prevalence (0.36%) and Type VII the highest prevalence (6.62%). DISCUSSION: Some of the studies included did not distinguish between the ''replaced'' and ''accessory'' ALHA (34.25%). Some surgical dissection techniques proved insufficient for the localization of other hepatic arteries. These results suggest that an accurate preoperative radiological evaluation is needed to localize replaced arteries.

The absence of the common hepatic artery and its implications for surgical practice: Results of a systematic review and meta-analysis.

INTRODUCTION: The common hepatic artery (CHA) is the main arterial supply to the liver. Common classifications of the anatomical variations of the celiac trunk have only marginally described the CHA. Currently, the only classification addressing anatomical variants in cases of CHA absence from the celiac trunk is that reported by Huang et al. In this systematic review, the prevalence of these variations, according to Huang's classification, have been analyzed. METHODS: The review was registered in PROSPERO (CRD 42018096679). The risk of bias was assessed using the AQUA tool. RESULTS: Fifty-four articles were included in the review (26,250 participants). The overall pooled prevalence estimate (PPE) of an absent CHA was 3.1%. Of those participants who underwent preoperative radiological evaluation, the overall PPE of an absent CHA was 3.8% for subjects who were evaluated via angiography and 3.0% for participants who underwent angio-CT evaluation. The overall PPE of an absent CHA was 3.9% in cadavers and 3.2% in participants evaluated surgically. Type I or Type II aberrations were the most common; in participants with CHA aberrations, 65.4% of those participants had either Type I or Type II aberrations. CONCLUSIONS: The overall PPE of an absent CHA was 3.1%, a result representing a significant, common anatomical variation. Our study revealed that an absence of a CHA was associated with a replaced CHA. The most common arterial variant was a replaced CHA originating from the Superior Mesenteric Artery and running across the anterior or posterior side of the pancreas (i.e., Types I and II).

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis.

BACKGROUND: Pancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula. METHODS: From January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C. RESULTS: Management of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the 'gently and softly' pancreatic manipulation, according literature, may be a risk factor. CONCLUSIONS: The authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Robotic pancreaticoduodenectomy in a case of duodenal gastrointestinal stromal tumor.

BACKGROUND: Laparoscopic pancreaticoduodenectomy is rarely performed, and it has not been particularly successful due to its technical complexity. The objective of this study is to highlight how robotic surgery could improve a minimally invasive approach and to expose the usefulness of robotic surgery even in complex surgical procedures. CASE PRESENTATION: The surgical technique employed in our center to perform a pancreaticoduodenectomy, which was by means of the da Vinci™ robotic system in order to remove a duodenal gastrointestinal stromal tumor, is reported. CONCLUSIONS: Robotic technology has improved significantly over the traditional laparoscopic approach, representing an evolution of minimally invasive techniques, allowing procedures to be safely performed that are still considered to be scarcely feasible or reproducible.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review.

INTRODUCTION: The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay. METHODS: For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST. RESULTS: We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison. CONCLUSIONS: NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Current status of robotic bariatric surgery: a systematic review.

BACKGROUND: Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review. METHODS: A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science. RESULTS: Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days). CONCLUSIONS: The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy).

Laparoscopic mechanical latero-lateral esophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results.

BACKGROUND: The realization of an esophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We report our laparoscopic experience in intracorporeal esophagojejunostomy. METHODS: Adults who underwent laparoscopic total gastrectomy for cancer with latero-lateral (functional termino-terminal) Roux en Y intracorporeal esophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra- and postoperative outcomes including 30-day readmissions and mortality were considered. RESULTS: Thirty-two patients were included. Nodal dissection D1 was 16. Median operative time was 280'. Median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent nonoperative management. Median postoperative stay was 8.5 days. CONCLUSIONS: This technique may improve the ergonomics of esophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

Laparoscopic versus open approach for adhesive small bowel obstruction, a systematic review and meta-analysis of short term outcomes.

BACKGROUND: Adhesive small bowel obstruction (ASBO) is one of the most frequent causes of emergency hospital admissions and surgical treatment. Current surgical treatment of ASBO consists of open adhesiolysis. With laparoscopic procedures rising, the question arises if laparoscopy for ASBO is safe and results in better patient outcomes. Although adhesiolysis was among the first surgical procedures to be approached laparoscopically, uncertainty remains about its potential advantages over open surgery. Therefore, we performed a systematic review and meta-analysis on the benefits and harms of laparoscopic surgery for ASBO. METHODS: A systematic literature review was conducted for articles published up to May 2019. Two reviewers screened all articles and did the quality assessment. Consecutively a meta-analysis was performed. To reduce selection bias, only matched studies were used in our primary analyses. All other studies were used in a sensitivity analyses. All the outcomes were measured within the 30th postoperative day. Core outcome parameters were postoperative mortality, iatrogenic bowel perforations, length of postoperative stay [days], severe postoperative complications, and early readmissions. Secondary outcomes were operative time [min], missed iatrogenic bowel perforations, time to flatus [days], and early unplanned reoperations. RESULTS: In our meta-analysis, 14 studies (participants = 37.007) were included: 1 randomized controlled trial, 2 matched studies, and 11 unmatched studies. Results of our primary analyses show no significant differences in core outcome parameters (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications, early readmissions). In sensitivity analyses, laparoscopic surgery favored open adhesiolysis in postoperative mortality (relative risk [RR], 0.36; 95% CI, 0.29-0.45), length of postoperative hospital stay (mean difference [MD], -4.19; 95% CI, -4.43 to -3.95), operative time (MD, -18.19; 95% CI, -20.98 to -15.40), time to flatus (MD, -0.98; 95% CI, -1.28 to -0.68), severe postoperative complications (RR, 0.51; 95% CI, 0.46-0.56) and early unplanned reoperations (RR, 0.82; 95% CI, 0.70-0.96). CONCLUSION: Results of this systematic review indicate that laparoscopic surgery for ASBO is safe and feasible. Laparoscopic surgery is not associated with better or worse postoperative outcomes compared with open adhesiolysis. Future research should focus on the correct selection of those patients who are suitable for laparoscopic approach and may benefit from this approach. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, Level III.

Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection.

BACKGROUND: Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. METHODS: Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. RESULTS: The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. CONCLUSIONS: This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.

The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience.

This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.

Diagnostic, therapeutic and health-care management protocol for major abdominal trauma at the "Santa Maria" Hospital of Terni. Analysis of the results after two years.

BACKGROUND: Trauma is the fourth leading cause of death and is more common in people under 45 age. Abdominal trauma is cause of death in 7-10% of traumatized patients. Aim is to evaluate the effectiveness of the diagnostic, therapeutic and health-care management protocol for major abdominal trauma. METHODS: A prospective study called DGR Azienda Ospedaliera S. Maria Terni n. 159. was registered on February 2014. Patients with abdominal major trauma admitted at Santa Maria Hospital of Terni from January 2015 to December 2016 were considered in this paper. Patients' demographics, comorbidities, application of the operative and non operative management (OM-NOM), Mortality, effectiveness of diagnostics were investigated. RESULTS: The most of the patients were the elderly. Staff members were compliant and operated in conformity to the protocol for abdominal trauma. Non operative management (NOM) was performed in 63% of patients, according to data from the literature. On the other hand data with respect to the performing of diagnostic examinations as Focused assessment with ultrasonography for trauma (FAST), chest X-ray, Computed Tomography (CT) were discordant with literature. No patient underwent damage control surgery (DCS). Number of missed injuries (3.3%) and overall (13.3%), daily and weekend mortality were similar to those from the available literature. In our experience, the best results were found regarding the sensitivity of the FAST and CT in unstable and stable patients respectively, and the lower incidence of: NOM failure (NOM 0%, NOM plus endovascular treatment 14.4%) , mortality in stable patients (2.3%) and night mortality (5%). CONCLUSIONS: Despite the application of trauma protocol at Terni Hospital has been effective it can be further improved. KEY WORDS: Diagnostic, Emergency surgery, Major Abdominal Trauma, Therapeutic and health-care management protocol.

Clinical signs of retroperitoneal abscess from colonic perforation: Two case reports and literature review.

RATIONALE: Retroperitoneal colonic perforation is a rare cause of retroperitoneal abscess. It presents, more frequently in frail elderly patients, with heterogeneous signs and symptoms which hamper the clinical diagnosis. Subcutaneous emphysema with pneumomediastinum and iliopsoas muscle abscess are unusual signs. Colonic retroperitoneal perforation may be consequent to diverticulitis or locally advanced colon cancer. Due to the anatomy of the retroperitoneal space and different physiopathology, diverticular perforation may present with air and pus collection; on the other hand perforated colon cancer may cause groin mass and psoas abscess. We reported 2 cases of colonic retroperitoneal perforation from diverticulitis and locally advanced colon cancer, respectively. Aim of this report is to improve differential diagnosis based on clinical signs. PATIENTS' CONCERNS: A 71-year-old man presented with pain in his left side, fatigue, fever, nausea, massive subcutaneous emphysema of the neck, and Blumberg sign in the left iliac fossa. A 67-year-old man presented with abdominal pain, sub-occlusion, left groin mass, left groin, and lower limb pain during walking, negative Blumberg sign. DIAGNOSIS: In the first patient the computerized tomography revealed pneumoperitoneum, gas in the mesosigma, pneumomediastinum, wall thickening of the descending colon, and retroperitoneal collection from diverticular perforation. In the second patient abdominal CT scan found thickening of the sigmoid colon adherent to the iliopsoas and fluid collection. INTERVENTIONS: In the first patient, a left hemicolectomy extending to the transverse colon, followed by a toilette and debridement of the retroperitoneum were performed. In the second patient, tumor of descending colon perforated in the retroperitoneum with iliopsoas abscess was treated with left hemicolectomy and a drainage of the abscess. OUTCOMES: The first patient underwent right colectomy with ileostomy in the 7 postoperative day for large bowel necrosis. He died of sepsis 2 days after. The second patient had regular postoperative and he is still alive. LESSONS: The spread of retroperitoneal abscess in complicated colonic diverticulitis is different from that in advanced colonic cancer. The former can present with a subcutaneous emphysema, the latter with a groin mass. Hence a thorough clinical examination and radiological studies are needed to diagnose these conditions.

Systematic review and meta-analysis on laparoscopic pancreatic resections for neuroendocrine neoplasms (PNENs).

INTRODUCTION: The safety of laparoscopic resections (LPS) of pancreatic neuroendocrine neoplasms (PNENs) has been well established in the literature. Areas covered: Studies conducted between January 2003 and December 2015 that reported on LPS and open surgery (OPS) were reviewed. The primary outcomes were the rate of post-operative complications and the length of hospital stay (LoS) after laparoscopic and open surgical resection. The rate of recurrence was the secondary outcome. Eleven studies were included with a total of 907 pancreatic resections for PNENs, of whom, 298 (32.8%) underwent LPS and 609 (67.2%) underwent open surgery. LPS resulted in a significantly shorter LoS (p < 0.0001) and lower blood loss (p < 0.0001). The meta-analysis did not show any significant difference in the pancreatic fistula rate, recurrence rate or post-operative mortality between the two groups. Expert commentary: LPS is a safe approach even for PNENs and it is associated with a shorter LoS.

Indications for the laparoscopic approach to acute small bowel obstruction: A retrospective review of 50 cases, a literature review, and a single hospital's preliminary experience.

Small bowel obstruction (SBO) is mainly caused by postoperative adhesions, but a broad spectrum of diseases may cause this pathogenetic condition. Laparoscopic treatment represents an efficient approach to SBO. The aim of this paper was to review a single center's experience with a minimally invasive approach to multiple pathologic scenarios causing SBO. From January 2010 to December 2012, 50 consecutive patients underwent laparoscopic surgery for mechanical SBO. In 90% of patients, the surgical procedure was totally laparoscopic, while 10% required conversion to midline laparotomy. In-hospital morbidity was 15% among totally laparoscopic patients and 40% among those who underwent conversion to midline laparotomy. Thirty-day mortality was zero. One patient died 4 months postoperatively from neoplastic disease progression; the remaining patients were free from occlusive symptoms at follow-up. The minimally invasive technique applies to a broad spectrum of cases. A larger cohort of patients seems necessary to reproduce our results and confirm the effectiveness of a laparoscopic approach to SBO.

Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review.

INTRODUCTION: Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon. METHODS: Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered. RESULTS: 11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique. DISCUSSION: there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field. CONCLUSION: The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.

Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula?

INTRODUCTION: The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important. METHODS: From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease. RESULTS: Postoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy. DISCUSSION: Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day. CONCLUSION: POPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.

Robotic versus Laparoscopic Approach in Colonic Resections for Cancer and Benign Diseases: Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis is to compare robotic colectomy (RC) with laparoscopic colectomy (LC) in terms of intraoperative and postoperative outcomes. MATERIALS AND METHODS: A systematic literature search was performed to retrieve comparative studies of robotic and laparoscopic colectomy. The databases searched were PubMed, Embase and the Cochrane Central Register of Controlled Trials from January 2000 to October 2014. The Odds ratio, Risk difference and Mean difference were used as the summary statistics. RESULTS: A total of 12 studies, which included a total of 4,148 patients who had undergone robotic or laparoscopic colectomy, were included and analyzed. RC demonstrated a longer operative time (MD 41.52, P<0.00001) and higher cost (MD 2.42, P<0.00001) than did LC. The time to first flatus passage (MD -0.51, P = 0.003) and the length of hospital stay (MD -0.68, P = 0.01) were significantly shorter after RC. Additionally, the intraoperative blood loss (MD -16.82, P<0.00001) was significantly less in RC. There was also a significantly lower incidence of overall postoperative complications (OR 0.74, P = 0.02) and wound infections (RD -0.02, P = 0.03) after RC. No differences in the postoperative ileus, in the anastomotic leak, or in the conversion to open surgery rate and in the number of harvested lymph nodes outcomes were found between the approaches. CONCLUSIONS: The present meta-analysis, mainly based on observational studies, suggests that RC is more time-consuming and expensive than laparoscopy but that it results in faster recovery of bowel function, a shorter hospital stay, less blood loss and lower rates of both overall postoperative complications and wound infections.

Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a "bridge" to elective laparoscopic sigmoidectomy?: a systematic review.

To this day, the treatment of generalized peritonitis secondary to diverticular perforation is still controversial. Recently, in patients with acute sigmoid diverticulitis, laparoscopic lavage and drainage has gained a wide interest as an alternative to resection. Based on this backdrop, we decided to perform a systematic review of the literature to evaluate the safety, feasibility, and efficacy of peritoneal lavage in perforated diverticular disease.A bibliographic search was performed in PubMed for case series and comparative studies published between January 1992 and February 2014 describing laparoscopic peritoneal lavage in patients with perforated diverticulitis.A total of 19 articles consisting of 10 cohort studies, 8 case series, and 1 controlled clinical trial met the inclusion criteria and were reviewed. In total these studies analyzed data from 871 patients. The mean follow-up time ranged from 1.5 to 96 months when reported. In 11 studies, the success rate of laparoscopic peritoneal lavage, defined as patients alive without surgical treatment for a recurrent episode of diverticulitis, was 24.3%. In patients with Hinchey stage III diverticulitis, the incidence of laparotomy conversion was 1%, whereas in patients with stage IV it was 45%. The 30-day postoperative mortality rate was 2.9%. The 30-day postoperative reintervention rate was 4.9%, whereas 2% of patients required a percutaneous drainage. Readmission rate after the first hospitalization for recurrent diverticulitis was 6%. Most patients who were readmitted (69%) required redo surgery. A 2-stage laparoscopic intervention was performed in 18.3% of patients.Laparoscopic peritoneal lavage should be considered an effective and safe option for the treatment of patients with sigmoid diverticulitis with Hinchey stage III peritonitis; it can also be consider as a "bridge" surgical step combined with a delayed and elective laparoscopic sigmoidectomy in order to avoid a Hartmann procedure. This minimally invasive staged approach should be considered for patients without systemic toxicity and in centers experienced in minimally invasive surgery techniques. Further evidence is needed, and the ongoing RCTs will better define the role of the laparoscopic peritoneal lavage/drainage in the treatment of patients with complicated diverticulitis.