Sutures in general surgery. New materials and advice.

The suture thread used in digestive surgery must have several characteristics, including resistance to tension until the anastomosis coalescence, rapid absorption to avoid complications, biocompatibility and ease of handling. The preference is for monofilament polymers as they offer greater guarantees in biliary-digestive anastomoses. Suturing with synthetic polymers and mechanical devices such as staplers are the most suitable techniques. It is believed that staplers may become the gold standard technique in robotic surgery based on their experience and experimental data. In general, the goal is to use materials that minimize the risk of post-operative complications and offer maximum reliability in the anastomosis. KEY WORD: Suture material, Stapler.

An international survey exploring the management of pilonidal disease.

AIM: Pilonidal disease (PD) is a common debilitating condition frequently seen in surgical practice. Several available treatments carry different benefit/risk balances. The aim of this study was to snapshot the current management of PD across European countries. METHOD: Members affiliated to the European Society of Coloproctology were invited to join the survey. An invitation was extended to others via social media. The predictive power of respondents' and hospitals' demographics on the change of therapeutic approach was explored. RESULTS: Respondents (n = 452) were mostly men (77%), aged 26-60 years, practising in both academic and public hospitals and with fair distribution between colorectal (51%) and general (48%) surgeons. A total of 331 (73%) respondents recommended surgery at first presentation of the disease. Up to 80% of them recommended antibiotic therapy and 95% did not use any classification of PD. A primary closure technique was the preferred procedure (29%), followed by open technique (22%), flap creation (7%), sinusectomy (7%) and marsupialization (7%). Approximately 27% of subjects would choose the same surgical technique even after a failure. Almost half (46%) perform surgery as office based. A conservative approach was negatively associated with acutely presenting PD (p < 0.001). Respondents who were not considering tailored surgery based on patient presentation tended to change their approach in the case of a failed procedure. CONCLUSION: With the caveat of a heterogeneous number of respondents across countries, the results of our snapshot survey may inform the development of future guidelines.

Sentinel Lymph Node Detection in Breast Cancer: An Innovative Technique.

(1) Background: Sentinel lymph node biopsy is important in the search for metastases, especially in patients with malignant breast disease. Our study proposed new techniques to prevent complications such as possible postoperative seroma formation, pain or hypoesthesia of the axillary cord and medial arm surface, as well as motor deficits, to avoid disabling outcomes and presents initial data from our experience with the sentinel lymph node biopsy technique. (2) Methods: We mainly used two radioactive tracer detection techniques and a new technique using a radiotracer called Sentimag-magtrace. The positive lymph node was located and removed to perform histologic analysis. In our study, we evaluate 100 patients who underwent breast cancer surgery. (3) Results: We calculated the identification rates of the different methods of sentinel lymph node detection and found that it was 88.9% using radioactive tracers vs. 89.5% using the magnetic tracer technology (Sentimag). (4) Conclusions: Thus, this technique avoids radiation exposure for both patients and health care providers, and can reduce costs and time.

Basosquamous Cell Carcinoma of the Nipple-Areola Complex-Report of a Case.

Basosquamous cell carcinoma (BSCC) is a rare malignancy usually arising on sun-exposed areas of the skin. BSCC is described as a rare variant of Basal cell carcinoma (BCC) which shows clinical and microscopic features of both BCC and of Squamous cell carcinoma (SCC). We report the case of a 70-year-old male with a cutaneous lesion of the nipple-areola complex (NAC); to the best of our knowledge, this is the first ever reported patient with BSCC in this area. The lesion had a fast growth, but, due to the COVID19 crisis, the patient only came to our observation one year after onset of this condition. Physical examination showed a bleeding red ulcerated lesion that involved the NAC, measuring 27 mm × 20 mm. Biopsy showed a BSCC. Pre-operative breast ultrasound scan, mammogram and MRI were all performed before surgery, which consisted of simple mastectomy and sentinel lymph-node biopsy. The patient was discharged home on the 4th post-operative day, and at 18-month follow-up there are no signs or clinical evidence of local recurrence or metastases. Diagnosis of BSCC of the nipple-areola complex requires high index of suspicion and a thorough differential diagnosis, management, and suitable radical treatment due to well described high rates of recurrence and of metastases. Differential diagnosis with similar lesions (e.g., Paget's disease, Bowen's disease, BCC, and SCC) should also be taken into account.

Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease.

AIM: Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique. RESULTS: A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%-6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%. CONCLUSION: The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of 'endoscopic sinusectomy', thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Vanishing Bile Duct Syndrome in an Adult Patient: Case Report and Review of the Literature.

Vanishing bile duct syndrome (VBDS) is a rare condition characterized by progressive loss, destruction, and disappearance of the intra-hepatic bile ducts, leading to cholestasis and ductopenia. The exact mechanism of development of VDBS has not been established yet. Diagnosis of VBDS mainly relies on clinical and disease related presentations, but liver biopsy is compulsory for diagnosis. Due to the low incidence reported in the literature, a standardized treatment of VDBS has not been established; hence, this rare condition must be managed at a tertiary liver referral center. Here, we report the management and treatment of VBDS of an 81-year-old woman without any history of exposure to antibiotics, neoplasms, etc.

The impact of experience on recurrence rates after biopsy punch excision for pilonidal disease.

AIM: We present the outcomes and the recurrences of 848 patients with pilonidal disease (PD) treated by biopsy punch excision (BPE) and we weigh our results against progressively obtained operative experience. BPE is a modified 'merged' version of both the Bascom 'pit picking' procedure and the Gips procedure. It employs biopsy punches of different calibre, depending on whether treatment is in the natal cleft (calibre as small as possible) or lateral (larger calibre punches or even small incision). Sometimes this procedure is referred to as the Bascom-Gips procedure. METHODS: In all, 848 consecutive patients with PD were treated from January 2011 until December 2016 (sex 622 [73.4%] men and 226 [26.6%] women; median age 26.2 years, mean age 24.6 ± 28.99 [range 14-55] years, men 25.1 years, women 24.8 years). Of these 848 patients, 287 were operated in 2011-2012, 301 in 2013-2014 and 260 in 2015-2016. The recurrence rates were recorded 12, 24 and 60 months after surgery both cumulatively and by examining the outcomes of the three biennia individually (years of treatment 2011-2012 or group A, 2013-2014 or group B, 2015-2016 or group C). RESULTS: The mean operating time was 34 ± 24.45 min. Postoperative complications included early (<24 h; n = 22 or 2.6%) and delayed (>24 h; n = 26 or 3.1%) postoperative bleeding. Postoperative fluid collections (<2 weeks) occurred in 83/848 patients (9.8%) and included haematoma (n = 25) and seroma (n = 58). Full recovery was obtained after a mean of 21 ± 12.72 days and work/school/university activities were resumed after a mean of 4 ± 12.02 days. Twelve-, 24- and 60-month follow-ups were possible in 725 (85.5%), 682 (80.4%) and 595 (70.2%) patients out of 848. An overall significant (ꭓ2  = 16.87, P = 0.0002) difference was found in the recurrence rates: 59 recurrences/725 patients (or 8.1%) after 1 year, 89 recurrences/682 patients (or 13.0%) after 2 years and 98 recurrences/595 (or 16.4%) after 5 years. However, when subgrouping patients in three 24-month subsets, the recurrence rates showed a steady and progressive decrease in the three biennia 2011-2012 (group A), 2013-2014 (group B) and 2015-2016 (group C) at 12-, 48- and 60-month follow-ups. Recurrences after 12 months were 29/225 (12.9%), 19/285 (6.7%) and 11/215 (5.1%) (ꭓ2  = 8.53, P = 0.014) in groups A, B and C respectively; after 24 months, 36/226 (15.9%), 31/242 (12.8%) and 22/214 (10.2%) (ꭓ2  = 2.38, P = 0.30 N.S.) in groups A, B and C respectively; after 60 months, 38/194 (19.5%), 36/215 (16.7%) and 24/186 (12.9%) (ꭓ2  = 2.23, P = 0.32) in groups A, B and C respectively. CONCLUSIONS: BPE is an effective, disease-targeted, minimally invasive and inexpensive way to treat PD. Its results are influenced by the experience of the team involved, especially regarding early recurrences/failure of surgery. At least 5-year follow-ups are needed to ascertain the outcome of surgery for PD.

Role of New Anatomy, Biliopancreatic Reflux, and Helicobacter Pylori Status in Postgastrectomy Stump Cancer.

Distal gastrectomy for benign gastroduodenal peptic disease has become rare, but it still represents a widely adopted procedure for advanced and, in some countries, even for early distal gastric cancer. Survival rates following surgery for gastric malignancy are constantly improving, hence the residual mucosa of the gastric stump is exposed for a prolonged period to biliopancreatic reflux and, possibly, to Helicobacter pylori (HP) infection. Biliopancreatic reflux and HP infection are considered responsible for gastritis and metachronous carcinoma in the gastric stump after oncologic surgery. For gastrectomy patients, in addition to eradication treatment for cases that are already HP positive, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the residual mucosa of any metaplastic-atrophic-dysplastic features following surgery.

Changes in daily energy expenditure and movement behavior in unilateral vestibular hypofunction: Relationships with neuro-otological parameters.

The vestibular system has been found to affect energy homeostasis and body composition, due to its extensive connections to the brainstem and melanocortin nuclei involved in regulating the metabolism and feeding behavior. The aim of this study was to evaluate - by means of a wrist-worn physical activity tracker and bioelectrical impedance analysis (BIA) - the energy expenditure (EE) in resting (REE) and free-living conditions and movement behavior in a group of chronic unilateral vestibular hypofunction (UVH) patients when compared with a control group (CG) of healthy participants. Forty-six chronic UVH and 60 CG participants underwent otoneurological (including video-Head Impulse Test [vHIT] for studying vestibulo-ocular reflex [VOR] and static posturography testing [SPT]), and EE and movement measurements and self-report (SRM) andperformance measures (PM). As well as significant (p < 0.001) changes in SPT variables (area and path length) and SRM/PM, UVH participants also demonstrated significantly (p < 0.001) lower values in REE, movement EE, hours/day spent upright, number of strides and distance covered and total daily EE (p = 0.007) compared to the CG. UVH patients consumed significantly lower Kcal/min in sweeping (p = 0.001) and walking upstairs and downstairs (p < 0.001) compared to the CG. Multiple correlations were found between free-living and resting EE and neuro-otological parameters in UVH participants. Since the melanocortin system could be affected along the central vestibular pathways as a consequence of chronic vestibular deafferentation, data collected by reliable wearables could reflect the phenomena that constitute an increased risk of falls and sedentary lifestyle for patients affected by UVH, and could improve rehabilitation stages.

"The Italian Study on Recovery 2" Phase 1: Psychometric Properties of the Recovery Assessment Scale (RAS), Italian Validation of the Recovery Assessment Scale.

BACKGROUND: The achievement of recovery is related to the notion of developing personal potential and restoring a legitimate social role, even against the backdrop of mental illness limitations. It is still difficult to fully understand this highly subjective and dynamic process. Therefore, in order to test the recovery process, specific tools, still only marginally used in our country, are needed. AIMS: The Italian Study on Recovery is the first study aimed at confirming the validity of the Italian version of the Recovery Assessment Scale (RAS), an instrument developed with the goal of detecting recovery among patients. METHOD: This multicentric research involved several Mental Health Services from various parts of Italy. The first phase of the study consisted in the administration of the Italian translation of RAS, previously used in a pilot study conducted in 2009. RAS was administered to 219 patients diagnosed with psychosis, whose mental disorder lasted for at least 5 years. RESULTS: Findings supported the good psychometric properties of the Italian version of RAS, demonstrating its capability of identifying patients matching the "in recovery" operational criteria. CONCLUSIONS: In consideration of the results highlighting the good psychometric properties of RAS, the present study may contribute to the diffusion of instruments to be included in Mental Health Service planning in the Italian context, in order to start a recovery-oriented transformation.

Preoperative staging of resectability of colon cancer using virtual colonoscopy: correlation with surgical results. Our experience.

PURPOSE: To evaluate the clinical usefulness of preoperative computed tomography colonography (CTC) in locoregional staging in patients with abdominal pain secondary toocclusive colorectal cancer (CRC). MATERIALS AND METHODS: 80 patients with abdominal pain underwent CTC initially without contrast and after diagnosis with contrast. 47 patients had distal CRC and 33 had proximal CRC. CTimages were analyzed independently by two radiologists, using MPR reconstruction and VR images. Depending on the anatomical depth of wall invasion primary tumor (T) was classified ≤ T2, T3 and T4. The definition of node disease (N) was based on the number of involved regional lymph nodes. Metastases (M) were characterized by the presence and location of distant disease. Pre treatment stage (cT cN) was compared with pathologic stage (pT pN). Accuracy of CTC was also evaluated. RESULTS: The overall accuracy values for T staging of reviewer 1, reviewer 2 and consensus reading were 91.6%, 86.2% and 92.8% respectively; 92.2%, 79.8% and 92.5% for T2; 88.1%, 85.5%, and 89.7% for T3; and 94.5%, 93.5% and 96.2% for T4. The accuracy values for N staging and M staging were 81,.8%, 94.0% for reviewer 1; 78.2% and 88.1% for reviewer 2; 81.8% and 94.0% for consensus reading, respectively. CONCLUSION: In our experience CTC is not only useful in the evaluation of the proximal bowel, but can also provide surgeons with accurate information about staging and tumor localization. CTC is recommended for better evaluation of preoperative staging. KEY WORDS: CT colonography, Colorectal cancer, Extracolonic findings, Staging.

Extent of lymphadenectomy and perioperative therapies: two open issues in gastric cancer.

Gastric cancer is one of the leading causes of death for cancer worldwide, although geographical variations in incidence exist. Over the last decades, its incidence and mortality have gradually decreased in Western countries, while these have increased, or remained stable, in the other world regions. Gastric cancer is often diagnosed at an advanced stage, with the only notable exception of Japan, where nationwide screening programs are enforced, due to local high incidence. Curative- intent surgery (i.e., gastrectomy, total or partial, and lymphadenectomy) remains the cornerstone of treatment of gastric cancer. Much has been debated about the extent of lymph node dissection and, although it is a valuable contribution to staging and cure, operative treatment only represents one aspect of overall effective management, as the risk of both locoregional and distant recurrences are high, and bear a poor prognosis. As a matter of fact, surgery, as a single modality treatment, has probably achieved its maximum efficacy for local control and survival, while other accompanying nonsurgical treatment modalities have to be taken into account, although their role is still the subject of considerable debate. The authors in this review present an update on the outcome of treatment of gastric cancer in relation to the extent of lymphadenectomy and of various nonsurgical preoperative, intraoperative, and postoperative strategies.

Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients.

PURPOSE: To evaluate the early and long-term postoperative results of malabsorptive surgery in morbidly obese patients. METHODS: Between 2000 and 2007, 102 morbidly obese patients were referred to the Department of Surgery "Pietro Valdoni", "Sapienza" University of Rome, Policlinico "Umberto I°", Rome, Italy for malabsorptive surgery. All patients underwent derivative biliodigestive surgery after they had been reviewed by a team of surgeons, physicians, dieticians, and psychologists. RESULTS: There were no intra-operative complications, but two patients suffered postoperative pulmonary embolisms, which resolved with medical treatment. The mean postoperative hospital stay was 7 days, with no early or late mortality. Maximum weight loss was reached 12-24 months after surgery, while the mean percentage excess weight loss at 3-5 years ranged from 45 to 64 %. Specific postoperative complications in the first 2 years after surgery were abdominal abscess (n = 2), gastroduodenal reflux (n = 4), and incisional hernia (n = 6). Diabetes resolved in 98 % of the diabetic patients within a few weeks after surgery and blood pressure normalised in 86.4 % of those who had had hypertension preoperatively. Obstructive sleep apnoea and obesity hypoventilation syndrome also improved significantly in 92 % of the patients. CONCLUSIONS: Morbidly obese patients can undergo biliodigestive surgery safely with good long-term weight loss and quality of life expectancy.

The role of radiotherapy in the carotid stenosis.

OBJECTIVE: Cervical radiation for head and neck cancer has been associated with an increased incidence of carotid arterial stenosis. Modern radiation therapy delivers higher doses with increasing long-term survival. In our study 50 patients with head and neck malignancies treated with radiotherapy are analized with colour Doppler ultrasonographic scanning of the carotid arteries. These patients were compared with a population of asymptomatic historical controls (40) These findings suggest that radiation has an adverse effect on large vessels. Colour Doppler follow-up may be indicated for patients receiving head and neck radiation therapy. METHODS: 50-70 Gy is the local dose that all patients received. during a period of about 8 weeks. The ecodoppler scan of carotid arteries was performed in all patients with estimation of Common and internal carotid artery's intimal medial thickness (IMT). Stenosis grade were divided into low (0-30%), moderate (31-49 %) and severe (= >50%). In add we considered ematochimics and flogosys parameters. Patients recruited from a hospital Radiation-oncology-surgery department from April 2007 to September 2011, 90 consecutive head and neck cancer patients were enrolled in this study. 50 of these patients had previously undergone RT (RT group) and 40 had no RT (control group). All patients were screened with bilateral carotid arterial duplex ultrasonography. We defined disease as "normal or mild" if the carotid stenosis was <50%, and "significant" if >50%. The relationship between standard demographic risk factors and screening outcomes was then analyzed. RESULTS: We found that severe carotid stenosis (= >50% ) was higher (41%) in patients who underwent to radiotherapy than in control group. The Eco Doppler examination demonstrated that the most affected site was Internal Carotid Arthery 's fork . There were no differences in age or gender between the two groups. The RT group had a significantly higher plaque score than the non-irradiated group. Bilateral plaque score was significantly correlated with age, hyperlipidemia, and RT. This analysis showed that in RT patients > 50 years old, age was inversely correlated with plaque score; however, in RT patients