Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak.

SETTING: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes. OBJECTIVES: This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG. PATIENTS AND METHODS: This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR). RESULTS: GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance. CONCLUSIONS: Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients.

BACKGROUND: Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF). PATIENTS AND METHODS: Patients were divided into four groups as follows: young (18-49); adult (50-69); and elderly (70-84), and very elderly (85-91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5-24 years). RESULTS: Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001). CONCLUSIONS: Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.

End-stage renal disease is a risk factor for complex laparoscopic cholecystectomy in patients waiting for renal transplantation.

Introduction: : To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD). Materials and Methods: We retrospectively analysed 321 patients undergoing LC during the period 2014-2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal-Wallis' test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model. Results: : Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001). Conclusion: : Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC.

Does bacterial translocation influence the postoperative infections in splenectomized patients after abdominal trauma?

BACKGROUND: Some studies suggested that after abdominal trauma, postoperative infections are associated with bacterial translocation, whereas others have not replicated these findings. We have assessed the bacterial translocation and postoperative infections in patients undergoing splenectomy after abdominal trauma, using a very homogeneous study population. METHODS: We consecutively studied, in a prospective observational clinical study, 125 patients who required urgent surgical treatment (splenectomy) following blunt abdominal trauma. For bacterial translocation identification, tissue samples were taken from liver, spleen and mesenteric lymph nodes (MLNs). Postoperative infectious complications in these patients were registered, confirmed by a positive culture obtained from the septic focus. Associations between clinical variables, bacterial translocation presence, and postoperative infection development were established. RESULTS: Bacterial translocation was detected in 47 (37.6%) patients. Postoperative infections were present in 29 (23.2%) patients. A significant statistical difference was found between postoperative infections in patients with bacterial translocation evidence (22 of 47 patients: 46.8%) in comparison with patients without bacterial translocation (7 of 78 patients: 8.9%) (P < 0.05). After multivariate adjustment analysis: a) the bleeding ≥ 1500 mL was significantly associated with the risk of bacterial translocation and, b) bacterial translocation was significantly associated with the risk of postoperative infections. Bacterial strains isolated from infection sites were the same as those cultured in MLNs in 48.3% of the cases (n = 14 of 29). CONCLUSIONS: There is higher risk of bacterial translocation in patients who required urgent surgical treatment (splenectomy) following blunt abdominal trauma and it is associated with a significant higher number of postoperative infections.

Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial.

BACKGROUND: A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF). MATERIALS AND METHODS: Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated. RESULTS: A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO2group patients in comparison with the 80% FiO2group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2group; no changes were noted in 80% FiO2group (P < 0.05). CONCLUSIONS: This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.

Septic Complications after Resection for Middle or Low Rectal Cancer: Role of Gut Barrier Function and Inflammatory Serum Markers.

BACKGROUND: The focus of this study was to understand the relationship between the failure of gut barrier function, inflammatory markers and septic complications after resection for extraperitoneal rectal cancer. METHODS: One hundred seven patients were enrolled into this prospective observational study and underwent open colorectal resection for extraperitoneal cancer. All patients underwent an assessment of intestinal permeability (L/M ratio), endotoxemia, interleukin-1ß (IL-1ß), interleukin-6 (IL-6), C-reactive protein (CRP) and elastase levels before surgery and on postoperative days 1, 3, and 7. RESULTS: Septic complications developed in 23.3% of patients. There were no significant differences in preoperative L/M ratio, endotoxine, CRP, interleukin-1 (IL-1), IL-6, and elastase levels between septic and non-septic groups. All patients showed a significant increase in intestinal permeability, endotoxemia, IL-1, IL-6, CRP, and elastase on the first postoperative day. At postoperative day 7, the septic group continued to demonstrate an increase in intestinal permeability, endotoxemia and elastase and significant difference was observed between the 2 groups (p < 0.05), whereas there was no significant difference in IL-1, IL-6, and CRP levels. CONCLUSION: The pattern of change in the postoperative period of intestinal permeability, systemic endotoxemia and elastase concentration is significantly higher in patients in whom sepsis develops, while the concentration of IL-1ß, IL-6, and CRP does not permit to distinguish infection from inflammation.

Effect of High Perioperative Oxygen Fraction on Surgical Site Infection Following Surgery for Acute Sigmoid Diverticulitis. A Prospective, Randomized, Double Blind, Controlled, Monocentric Trial.

UNLABELLED: Propose: The clinical role of hyperoxiato prevent postoperative surgical site infection (SSI) remains uncertain since randomized controlled trials on this topic have reported different results. One of the principal reasons for such mixed results can be that previous trials have entered a heterogeneous population of patients and set of procedures. The aim of our study was to assess the influence of hyperoxygenation on SSI usingan homogeneous study population. METHODS: We studied, in a prospective randomized study, extended on a time interval January 2009 to May 2015, 85 patients who underwent open intraperitoneal anastomosis for acute sigmoid diverticulitis. Patients were assigned randomly to an oxygen/air mixture with a faction of inspiration (FiO2) of 30% (n=43) or 80% (n=42). Administration was started after induction of anesthesia and maintained for 6 hours after surgery. RESULTS: The overall wound site infection rate was 24.7% (21 out of 85): 14 patients (32.5%) had a wound infection in the 30% FiO2 group and 7 (16.6%) in the 80% FiO2 group (p 0.05). The risk of SSI was 43% lower in the 80% FiO2 group (RR, 0.68; 95% confidence interval, 0.35-0.88) versus 30% FiO2. CONCLUSIONS: Therefore, supplemental 80% FiO2 during and 6 hours after open surgery for acute sigmoid diverticulitis, reducing post-operative SSI, should be considered part of ongoing quality improvement activities related to surgical care, accompanied by few risk to the patients and little associates cost.

Complications after bowel resection for inflammatory bowel disease associated cancer: a systematic literature review.

INTRODUCTION: Inflammatory bowel disease (IBD) associated colorectal cancer represents the 1-2% of all patients affected by colorectal carcinoma, but it is frequent responsible for death in these patients. Aim of this systematic review was to report the complications after bowel resection in patients with IBD associated cancer. EVIDENCE ACQUISITION: A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was carried out in PubMed, Embase, Cochrane and Web of Science databases. A total of 54,084 articles were found. Of these 38,954 were eliminated because were duplicates between the searches. Of the remaining 15,130 articles, 14,888 were excluded after screening title and abstract. EVIDENCE SYNTHESIS: Two-hundred-forty-two articles were fully analyzed, and 239 further articles were excluded. Finally, three articles were included for a total of 63 patients. Overall, 38 early postoperative complications (60.3%) were observed. Of these, anastomotic leakage occurred in 13 patients (20.6%). The indication for surgery was ulcerative colitis in 52 patients (82.5%), Crohn's disease in 8 patients (12.7%) and indeterminate colitis in 3 patients (4.8%). Intraoperative complications, readmission and postoperative mortality were not observed. CONCLUSIONS: Complication rate after bowel resection for IBD associated cancer is not different from complication rate after colorectal surgery for other diseases. Given the high probability of developing a cancer and the time correlated occurrence of malignancy in IBD patients, it should be debated if a surgical resection should be performed as soon as dysplasia is detected in IBD patients or earlier in their life.

Unusual presentation of primary myelofibrosis with spontaneous bleeding after laparoscopic adrenalectomy: A case report.

INTRODUCTION: We described unusual presentation of primary myelofibrosis with spontaneous bleeding after laparoscopic adrenalectomy. This case is written following the SCARE criteria. PRESENTATION OF CASE: A 73 years old Caucasian man underwent laparoscopic right adrenalectomy for a rapidly increasing expansive mass (3.5 × 2.5 cm) of the right adrenal gland. The night of intervention, patient underwent urgent explorative laparotomy, that highlighted massive haemoperitoneum, clots in the abdomen, on the splenic side, on Morrison's space, and at the confluence between right renal vein and inferior vena cava. Surgical specimen examination showed extra-medullary myeloid proliferation of the right periadrenal tissue. DISCUSSION: Bone marrow biopsy was performed. The list of differential diagnoses included: chronic myelomonocitic leukaemia, atypical CML and primary myelofibrosis (PMF). After discharge, several results became available: conventional cytogenetics was normal, PDGFR-α, PDGFR-ß and FGFR1 mutations were negative but V617 F mutation of the JAK2 gene was positive. Therefore, the final diagnosis was pre-fibrotic primary myelofibrosis according to the 2016 WHO classification, Dynamic International Prognostic Scoring System (DIPSS) plus 2 (intermediate-2). CONCLUSION: To our knowledge, we report uncommon case of primary myelofibrosis associated with extra-medullary myeloid proliferation of the right periadrenal tissue.

Biliary Stones After Brain Dead Liver Transplantation Today: Rates, Risk Factors, Treatments, and Outcomes.

AIMS: Our aim was to review the rate of biliary duct stones (BDS) after liver transplantation (LT), risk factors, and treatments, and to identify predictive factors for their onset. METHODS: LTs performed in our center from 2004 to 2014 were studied. Risk factors for the onset of BDS were identified using univariable Cox's proportional hazards models. RESULTS: Three hundred and sixty-four grafts with 317 duct-to-duct end-to-end biliary anastomosis on a T-tube and 47 hepaticojejunal anastomosis (HJ) were analyzed. BDS were identified in 13 of 364 (3.5%) grafts, including 10 duct-to-duct end-to-end biliary anastomosis on a T-tube grafts (3.2%) and 3 HJ grafts (6.4%). Predictive factors for BDS were biliary strictures (hazard ratio [HR] 9.94; 95% confidence interval [95% CI] 3.25-30.4), bilirubin (HR 1.04; 95% CI 1.01-1.06, for 1 unit increase), Model for End-Stage Liver Disease score (HR 1.07; 95% CI 1.01-1.14, for 1 unit increase), surgery time (HR 1.04; 95% CI 1.01-1.08, for 10-minute increase), hepatocellular disease (HR 8.3; 95% CI 1.09-64.0), hepatic artery thrombosis (HR 6.71; 95% CI 1.47-30.6), and retransplantation (HR 3.69; 95% CI 1.02-13.43). Among 51 grafts (14%) with biliary strictures, female sex was identified as a risk factor for BDS (HR 5.19; 95% CI 1.29-20.98). Multimodality treatment of BDS was often successful but open surgery was still needed in 23% of them. One-, 5-, and 10-year graft survival was not influenced by the onset of BDS. CONCLUSION: Main predictive factor for BDS in liver grafts is biliary stricture. Recipient's age and body mass index failed to show any statistical importance. In grafts with biliary strictures, female sex is the main risk factor for BDS. In the absence of biliary strictures, hepatic artery thrombosis lead to an increase in the risk of BDS. Multimodality treatment of BDS is often successful. BDS do not influence outcome.

Peri-prostatovesicular smooth muscle tumors of undetermined malignant potential: a case report.

INTRODUCTION: Smooth muscle tumors of undetermined malignant potential (STUMPs) are atypical smooth muscle tumors, most of which derived from uterine tissue. STUMPs of male genitourinary system and of the male pelvic organs are uncommon. CASE DESCRIPTION: In this report, we describe the first case of peri-prostatovesicular STUMP that was treated with laparoscopic excision, in a young asymptomatic man. CONCLUSIONS: In most cases, the definitive diagnosis can be made only after surgical resection and accurate histological examination. The usefulness of adjuvant chemotherapy remains unclear, and a standardized follow-up protocol has not been described.

The Effects of High-Concentration Oxygen on Inflammatory Markers in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

BACKGROUND: This study assessed effect of administration of high-concentration supplemental perioperative oxygen on systemic inflammatory and immune response in patients undergoing elective laparoscopic cholecystectomy. MATERIALS AND METHODS: One hundred seventy-seven patients were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n=88) or 80% (n=89). White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-1 and IL-6, and C-reactive protein were investigated. RESULTS: Significantly higher concentration of neutrophil elastase, IL-1, IL-6 and C-reactive protein was detected postoperatively in the 30% FiO2 group patients in comparison with the 80% FiO2 group (P<0.05). Statistically significant change in human leukocyte antigen-DR expression was recorded postoperatively at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2 group. CONCLUSIONS: This study demonstrated that high-concentration (80%) supplemental perioperative oxygen can lead to a reduction in postoperative inflammatory response and avoid postoperative immunosuppression.

Intraluminal ileal tumour after right hemicolectomy for cancer: An implantation recurrence or a new cancer? A case report.

INTRODUCTION: Extra-anastomotic intraluminal recurrence of the colon cancer after curative surgery was rarely reported but intraluminal ileal relapse has not been described to date.We report a case of intraluminal ileal tumor arising after curative right hemicolectomy that could be ascribed to an implantation of exfoliated cancer cells. CASE REPORT: A 71-years old man was admitted with no metastatic stenotic adenocarcinoma of the hepatic flexure and submitted, without preoperative bowel preparation, to right hemicolectomy using a "no-touch" technique. Histology showed moderately differentiated adenocarcinoma without lymph nodes involvement (pT3N0). No adjuvant therapy was prescribed. First colonoscopy three months after surgery was negative but a second endoscopic examination nine months later revealed an ileal neoplasia, presenting like an ulcer 10 cm proximally to ileocolic anastomosis. A new ileo-colic resection including past anastomosis was performed with curative intent. Pathological examination showed moderately differentiated adenocarcinoma extended to peri-visceral fat tissue with 10 tumor-free lymph nodes. (pT3N0). Six courses of Capecitabine adjuvant chemotherapy was prescribed and 32 months after second surgery, the patient is alive without disease. DISCUSSION: In the present case, the relatively short time from the primary surgery and the fact that recurrence occurred outside the anastomosis suggest that implantation of exfoliated malignant cells seems to be the main pathogenetic mechanism. We suppose that the high grade of primary cancer and the occlusive condition could have promoted the cancer cells reflux through the ileocecal orifice and in the transverse colon. CONCLUSION: This case seems to confirm the intraluminal implanting capacity of exfoliated carcinoma cells.

Spontaneous liver rupture associated with anticoagulant therapy A case report.

Spontaneous hepatic rupture without underlying liver diseases is uncommon entity. We report a rare case of spontaneous rupture of liver hematoma in patient treated with warfarin end enoxaparin sodium because of pulmonary embolism. Two day after admission the patient complained generalized abdominal pain and hemodynamic instability. The abdominal US and TC scan revealed free fluid and lesion at right liver lobe. The patient, despite intravenous fluid support and blood transfusion, was hemodinamically instable and urgent laparotomy was needed. At laparotomy, it was found that a subcapsular haematoma, involving the diaphragmatic face of the right liver, had ruptured into peritoneum. Hepatic bleeding was stopped using a conservative approach by Pringle manoeuvre, parenchymal suture and fibrin sealant. There was no complication related to hepatic surgery but the patient died because of new massive pulmonary embolism 10 days after surgery. The absence of underlying liver pathology was confirmed by autopsy examination. This case report suggests that the possibility of spontaneous liver rupture should be considered in patients being treated with oral anticoagulants. Early diagnosis are critically important given the high morbidity and mortality. Aggressive resuscitation and immediate exploratory laparotomy is needed when hemodynamic instability occurs. In our case a quick, safe and effective control of bleeding was provided by partial vascular occlusion, parenchymal suture and topical haemostatic agent. KEY WORD: Anticoagulant therapy, Araumatic hemoperitoneum, Liver hematoma.

Reconstruction of Scrotal Sac and Penis with Biological Prosthesis and Vacuum Therapy.

Fournier's gangrene is a rapidly progressing necrotizing fasciitis, involving perineal, perianal, or genital regions, and it constitutes a true surgical emergency. Surgical excision of all necrotic tissue is required, and multiple debridements may be necessary to remove all nonviable tissue. After surgical intervention for debridement, reconstruction may be necessary. We present our experience in the treatment of tissue loss after Fournier's gangrene of genital and perianal regions with the use of biological mesh (derma porcine mesh) in association with vacuum-assisted closure therapy.

Gastroduodenal major haemorrhages in critical patients: an original surgical technique.

AIM: Upper gastrointestinal bleeding represents today a serious pathology with two important problems: mortality and correct management. Our study is a review of recent and past licterature about causes, diagnosis and treatment of upper gastrointestinal bleeding. PERSONAL EXPERIENCE: The Authors describe an original surgical technique in treating patients with gastroduodenal haemorrhages and critical circulatory-coagulative conditions. Any surgical resective procedure could be absolutely inacceptable for the rates in morbility and mortality in these absolutely instable patients. We approached the problem with a control damage surgery by endoluminal packing of the stomach or the duodenum.