Different characteristics of circular staplers make the difference in anastomotic tensile strength.

Anastomotic leak after gastrointestinal surgery is a severe complication associated with relevant short and long-term sequelae. Most of the anastomoses are currently performed with a surgical stapler that is required to have appropriate characteristics in order to guarantee good performances. The aim of our study was to evaluate, ex vivo, pressure resistance and tensile strength of anastomosis performed with different circular staplers available in the market. We studied 7 circular staplers of 3 different companies, 3 of them used for gastrointestinal anastomosis and 4 staplers for hemorrhoidal prolapse excision. A total of 350 anastomoses, 50 for each of the 7 staplers, were performed using healthy pig fresh intestine, then injected saline solution and recorded the leaking pressure. There were no statistically significant differences between the mean pressure necessary to induce an anastomotic leak in the various instruments (p>0.05). For studying tensile strength, we performed a total of 350 anastomoses with 7 different circular staplers on a special strong paper (Tyvek), and then recorded the maximal tensile force that could open the anastomosis. There were statistically significant differences between one brand stapler vs other 2 companies staplers about the strength necessary to open the staple line (p<0.05). In conclusion, we demonstrated that different circular staplers of three companies available in the market give comparable anastomotic pressure resistance but different tensile strengths. This is probably due to different technical characteristics.

Hemorrhoids and anal fissures in inflammatory bowel disease.

Perianal disease is a common complication of inflammatory bowel disease (IBD). It includes different conditions from more severe and potentially disabling ones, such as abscesses and fistulas, to more benign conditions such as hemorrhoids, skin tags and fissures. Most literature has been focused on anal sepsis and fistulae, as they carry the majority of disease burden and often alter the natural course of the disease. Hemorrhoids and anal fissures in patients with IBD have been overlooked, although they can represent a challenging problem. The management of hemorrhoids and fissures in IBD patients may be difficult and may significantly differ compared to the non-affected population. Historically surgery was firmly obstructed, and hemorrhoidectomy or sphincterotomy in patients with associated diagnosis of IBD was considered harmful, although literature data is scant and based on small series. Various authors reported an incidence of postoperative complications higher in IBD than in the general populations, with potential severe events. Considering that a spontaneous healing is possible, the first line management should be a medical therapy. In patients non-responding to conservative measures it is possible a judicious choice of surgical options on a highly selective basis; this can lead to acceptable results, but the risk of possible complications needs to be considered. In this review it is analyzed the current literature on the incidence, symptoms and treatment options of hemorrhoids and anal fissures in patients with Crohn's disease and ulcerative colitis.

Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh. METHODS: Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index = FISI) and constipation (measured with the Wexner Constipation Score = WCS) at 3, 6 and 12 months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25 % and a cure if the FISI score decreased to <10 and the WCS decreased to <5. RESULTS: Between April 2009 and April 2013, 100 consecutive female patients (mean age 63 years, range 24-88 years) underwent LVR. All patients had internal rectal prolapse (grade III [n = 25] and grade IV [n = 75] according to the Oxford classification) and rectocele. Mean operative time was 85 ± 40 min. Conversion rate to open technique was 1 %. There was no post-operative mortality. Overall 16 patients (16 %) experienced 18 complications, including rectal perforation (n = 1), small bowel obstruction (n = 2), urinary tract infection (n = 8), subcutaneous emphysema (n = 3), wound haematoma (n = 2), long lasting sacral pain (n = 1) and incisional hernia (1). Median post-operative length of stay was 2 days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p = 0.003) to 3.3 ± 2.3 SD (p = 0.04). Incontinence improved in 37 out of 43 patients (86 %), and 31 patients (72 %) were cured. Similarly, the mean WCS score improved from 18.4 ± 11.6 SD to 5.4 ± 4.1 SD (p = 0.04). Constipation improved in 82 out of 89 patients (92 %), and 70 patients (79 %) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14 %) experienced persistence or recurrence of prolapse. CONCLUSIONS: LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

Defecatory disorders in anorexia nervosa: a clinical study.

BACKGROUND: Defecatory disorders in patients with eating disorders have been overlooked. We evaluated the prevalence and type of defecatory disorders in patients with anorexia nervosa. METHODS: The aim of our questionnaire-based study was to determine the prevalence of constipation and faecal incontinence (FI) in patients with anorexia nervosa attending our dedicated eating disorders outpatient clinics and whether length of illness and low body mass index (BMI) exacerbate both constipation and FI. The Wexner constipation score (WCS), Altomare's obstructed defecation score (OD score) and the faecal incontinence severity index (FISI) were used to evaluate constipation and incontinence. A WCS ≥5, OD score ≥10 and a FISI ≥10 were considered clinically relevant. RESULTS: Eighty-five patients (83 females; mean age 28 years ± 13) with anorexia nervosa (study group) and mean BMI of 16 ± 2 kg/m(2) (range 14-19 kg/m(2)) were studied. This group was compared to 57 healthy volunteers (control group) with mean BMI of 22 ± 3 kg/m(2) (range 20-27 kg/m(2)). In the study group, 79/85 (93%) patients suffered from defecatory disorders defined as at least one abnormal score, either WCS, OD score or FISI, compared to 7/57 (12%) controls (p < 0.001). Constipation (defined as WCS ≥5) was present in 70/85 (83%) patients with anorexia and in 7/57 (12%) controls (p = 0.001), while obstructed defecation syndrome (defined as OD score ≥10) was present in 71/85 (84%) patients with anorexia and 7/57 (12%) controls (p < 0.001). In patients with anorexia, the mean WCS score was 10 ± 5 standard deviation (SD) (3 ± 2 SD in controls; p < 0.001), and the mean OD score was 12 ± 4 SD (3 ± 4 SD in controls; p < 0.001). Overall, 62/85 (73%) patients with anorexia had FI defined as FISI score ≥10, and the mean FISI score in anorexia patients was 12 ± 9 SD. A combination of constipation and FI (either both WCS and FISI abnormal or both OD score and FISI abnormal) was present in 55/85 (64%) and 8/85 (9%) presented with FI alone. Moreover, all results are influenced by the severity of the disease measured by BMI and duration. The percentage of defecatory disorders rises from 75 to 100% when BMI is <18 kg/m(2) and from 60 to 75% when the duration of illness is ≥5 years (p < 0.001 and p = 0.021, respectively). CONCLUSIONS: Defecatory disorders are associated with anorexia nervosa and increased with the duration and severity of the illness.

Modified laparoscopic ventral mesh rectopexy.

We present a modified laparoscopic ventral mesh rectopexy procedure using biological mesh and bilateral anterior mesh fixation. The rectopexy is anterior with a minimal posterior mobilization. The rectum is symmetrically suspended to the sacral promontory through a mesorectal window.

Bariatric surgery in moderately obese patients: a prospective study.

Introduction. Moderate obesity (BMI 30-35 kg/m(2)) affects 25% of the western population. The role of bariatric surgery in this context is currently debated, reserved for patients with comorbidity, as an alternative to conservative medical treatment. We describe our experience in moderately obese patients treated with bariatric surgery. Materials and Methods. Between September 2011 and September 2012, 25 patients with grade I obesity and comorbidities underwent bariatric surgery: preoperative mean BMI 33.2 kg/m(2), 10 males, mean age 42 years. In presence of type 2 diabetes mellitus (T2DM) (56%), gastric bypass was performed; in cases with hypertension (64%) and obstructive sleep apnea (OSA) (12%), sleeve gastrectomy was performed. All operations were performed laparoscopically. Results. Mean follow-up was 12.4 months. A postoperative complication occurred: bleeding from the trocar site was resolved with surgery in local anesthesia. Reduction in average BMI was 6 points, with a value of 27.2 kg/m(2). Of the 14 patients with T2DM, 12 (86%) discontinued medical therapy because of a normalization of glycemia. Of the 16 patients with arterial hypertension, 14 (87%) showed remission and 2 (13%) improvement. Complete remission was observed in patients with OSAS. Conclusions. The results of our study support the validity of bariatric surgery in patients with BMI 30-35 kg/m(2). Our opinion is that, in the future, bariatric surgery could be successful in selected cases of moderately obese patients.

Collagen matrix injection combined with flap repair for complex anal fistula.

Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non-cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two-staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two-stage approach seems to be safe and effective.

Saving time stitching thick biological mesh during laparoscopic ventral rectopexy.

We present a trick to save time at stitching of thick biological mesh during laparoscopic ventral mesh rectopexy by the use of a belt hole puncher.

Ligation of the intersphincteric fistula tract (LIFT) to treat anal fistula: early results from a prospective observational study.

BACKGROUND: Ligation of the intersphincteric tract (LIFT), a novel sphincter-saving technique, has been recently described with promising results. Literature data are still scant. In this prospective observational study, we present our experience with this technique. METHODS: Between October 2010 and April 2011, 18 patients with 'complex' fistulas underwent LIFT. All patients were enrolled in the study after a physical examination including digital examination and proctoscopy. For the purpose of this pilot study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula or pre-existing incontinence. Endpoints were healing time, presence of recurrence, faecal incontinence and surgical complications. RESULTS: Ten patients were men and 8 were women; mean age was 39 years; minimum follow-up was 4 months. Three patients required drainage seton insertion and delayed LIFT. After LIFT, 1 patient experienced haemorrhoidal thrombosis. At the end of the follow-up, 15 patients (83%) healed with no recurrence. Three patients had persistent symptoms and required further surgical treatment. We did not observe postoperative worsening of continence. CONCLUSIONS: Results from our pilot study indicate that this novel sphincter-saving approach is effective and safe for treating complex anal fistula.

Open tension-free Lichtenstein repair of inguinal hernia: use of fibrin glue versus sutures for mesh fixation.

PURPOSE: To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures. METHODS: Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol(®)/Tisseel(®)) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale (VAS; 0 [no pain] to 10 [worst pain]). RESULTS: One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P < 0.001). At 1 month, significantly fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group (all P < 0.05). Fibrin glue patients also experienced less intense pain (0.6 vs. 1.2; P = 0.001). By 3 months, the between-group differences had disappeared, except for numbness, which was more prevalent in the sutures group. By 12 months, very few patients reported complications. CONCLUSIONS: Tissucol fibrin glue for mesh fixation in the Lichtenstein repair of inguinal hernia shows advantages over sutures, including lower incidence of complications such as pain, numbness, and discomfort, and should be considered as a first-line option for mesh fixation in hernioplasty.

Laparoscopic treatment of a gastric diverticulum.

Gastric diverticula are rare disorders which present usually with vague upper abdominal symptoms. The diagnosis is based on endoscopic and radiologic findings, but it may remain uncertain until the operation. Herein we report the case of a 46-year-old woman with a diverticulum of the posterior aspect of the upper part of the gastric fundus, referred to our attention for epigastric pain. The preoperative work out evidenced a pouch of the gastric fundus which was misinterpreted as a paraesophageal or a diaphragmatic hernia. The operation was performed by laparoscopy with a 4-port technique and the diverticulum was resected by an endoscopic stapler. The patient is well and symptom-free more than two months after the operation.

Radius surgical system and conventional laparoscopic instruments in abdominal surgery: application, learning curve and ergonomy.

We illustrate our experience with a new class of instruments, the mechanical manipulators (MM), whose main features are an improved mobility, and ergonomy and a modular structure. A specific MM, the Radius Surgical System (RADIUS), has been used both for educational purposes as well as in clinical studies, demonstrating that it can represent an efficient tool to support surgeons performing surgical complex procedures, with a short learning curve for the postural attitude.

Bloodless hepatic resection with automatic bipolar radiofrequency generator and multielectrode device.

Liver resection is a standard treatment for liver tumours. Intra-operative blood loss remains a major concern during liver resection due to its association with higher postoperative complications and shorter long-term survival. To perform bloodless hepatic resection we realized an apparatus consisting of an incremental, bipolar radiofrequency generator and a probe with six in-line needles (SURTRON SB). Several ex-vivo and in-vivo pig liver experiments and a first-phase clinical study allowed the realization of a prototype radiofrequency (RF) generator that works at 470 kHz, 150 watts maximum power delivered. The probe consists of six needle electrodes of 1.5 mm diameter, with 4.5 mm free space, 6.0 mm centre to centre, between each. We obtained a coagulation of 35 mm length and 12 mm width. The transection was performed with a common scalpel after coagulation of liver parenchyma. We observed good healing of the liver edge both in animal model and in ongoing pilot clinical study. Coagulation with SURTRON SB allows a feasible, easy and safe bloodless liver resection. This method is tolerated with no systemic complication or adverse reaction. This technique offers a method for a bloodless hepatic transection without the need for sutures, ties, staples or tissue glue.

Clinical evaluation of fibrin glue in the prevention of anastomotic leak and internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial.

BACKGROUND: Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP. METHODS: A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m2, aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months. RESULTS: To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0+/-11.6 years, BMI 46.4 +/- 8.2) and 93 in the fibrin glue group (mean age 42.9+/-11.7 years, BMI 46.9+/-6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P = 0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165). CONCLUSION: The preliminary results suggest that Tissucol application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.

Anabolic steroid nandrolone augments hepatic regenerative response in rats.

The success of recovery after liver resection depends on the regeneration and functions of the remnant liver. In this study we investigated whether liver regeneration was facilitated by nandrolone decaonate after two-thirds partial hepatectomy in rats. Study animals were pretreated with nandrolone (5 mg/kg), while control animals received a placebo. Animal were sacrificed at 12, 24, 48, and 72 hours. We compared the survival rates, liver function tests as well as the amount of apoptosis by terminal deoxynucleotidyl transferase-mediated deoxyuridine-biotin nick end labeling assay, and regeneration, which was expressed as ratio of proliferating cell nuclear antigen and restoration ratio. A significant increase in hepatocyte regeneration at 24 and 48 hours in partially hepatectomized rats treated with nandrolone decaonate was observed compared to controls. This observation was confirmed by the significant acceleration of the liver restoration rate, which was 1/5 faster than in partially hepatectomized controls. The results of this study indicate that liver regeneration in rats treated with nandrolone show a prompt, faster regeneration after partial hepatectomy.

Ischemic preconditioning protects intestine from prolonged ischemia.

Ischemic preconditioning (IP), obtained by exposure to brief periods of vascular occlusion, improves organ tolerance to prolonged ischemia. The aim of this study was to evaluate the effects of IP on intestinal morphology. Forty rats were subjected to sham surgery (n = 20, group I) or intestinal preconditioning (n = 20, group II) with a cycle of brief ischemia/reperfusion (10-minute occlusion of superior mesenteric artery [SMA], followed by 10-minute reperfusion) before prolonged ischemia produced by SMA occlusion (45 minutes). Five animals in each group were sacrificed 2, 12, 24, and 48 hours after reperfusion. Intestinal samples were processed for light and electron microscopy. A TUNEL assay was performed to detect apoptosis. Statistical analysis used Student t test and Kaplan-Meier survival curves. The overall mortality for the sham-operated group was 15%, while no animals of group II died (NS). Histological evaluation showed early detachment of epithelial cells from villous stroma accompanied by marked congestion and edema. Successive morphological changes were represented by leukocyte infiltration, focal necrosis, and marked villus denudation or loss. Group II animals showed significantly reduced inflammatory infiltrates in the lamina propria and a greater villus height compared to group I. The maximum number of apoptotic nuclei was observed in both groups, Following 2 hours of reperfusion group II animals showed significantly, greater apoptosis at 2 and 12 hours after reperfusion (P <.05). Electron microscopy showed severe mitochondrial and basement membrane damage. The findings from this study confirm that IP preconditioning attenuates morphological alterations that are invariably present after prolonged ischemia and reperfusion.

Melatonin reduces bacterial translocation after intestinal ischemia-reperfusion injury.

Melatonin, the primary pineal hormone, has been reported to protect from oxidative injury after ischemia-reperfusion (IR). The aim of this study was to evaluate the effects of exogenous melatonin on intestinal integrity, ileal colonization, and bacterial translocation 45-minute after mesenteric IR. Sixteen male ACI rats randomly divided into two groups underwent 45-minutes intestinal ischemia by clamping the superior mesenteric artery. One hour prior to ischemia, study animals (n=8, group A) were treated with melatonin (10 mg/kg IP) while control animals (n=8, group B) received the same volume of saline solution. An additional six animals underwent laparotomy and served as a sham-operated group. Animals were sacrificed 24 hours after reperfusion; peritoneal swabs and biopsies of liver, spleen, lung, mesenteric lymph nodes, cecum, and terminal ileum were obtained for microbiology. The ileum samples were also processed for histopathological evaluation of IR-induced injury. Twenty-four hours after reperfusion bacterial translocation to the peritoneal cavity present in all group B animals was reduced to 37.5% among those that were melatonin-treated (group A; P <.05). Furthermore bacterial translocation to mesenteric lymph nodes, spleen, and liver was significantly lower in group A than group B (P <.05). Although cecal and ileal counts did not differ between the two groups, ileal counts from control animals showed increased colonization. Accordingly, a single injection of exogenous melatonin significantly reduced the intestinal IR injury and prevented bacterial translocation.

Percutaneous liver biopsy using an ultrasound-guided subcostal route.

Percutaneous biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases. The introduction and widespread diffusion of ultrasounds in medical practice has improved percutaneous bioptic technique, while reducing postoperative complications. Although ultrasonography has become almost ubiquitous in prebiopsy investigation, only one third of biopsies are performed under ultrasound control. Moreover, the one-day procedure, reported in several studies to be safe and cost effective, accounted for only 4% of biopsies done. We report our experience of 142 percutaneous US-guided biopsies performed on 140 patients affected by chronic diffuse liver disease over a four-year period. Liver biopsies were performed under US guidance at the patient's bed using an anterior subcostal route. We evaluated postoperative pain, modifications of blood pressure and red cell count, hospital stay, morbidity and mortality rates, and adequacy of specimens for histologic examination. There was no operative mortality. As for major complications, one case of hemobilia occurred. As for minor complications, two cases of persistent postoperative pain required analgesic therapy. Patients were discharged the day following the procedure in all cases but two, who were discharged on the third and fifth postoperative days. Liver specimens were suitable for histologic diagnosis in all but one case, in which there were no portal spaces. According to our experience, we believe that hepatic biopsy guided by ultrasonography could replace blinded biopsy in the diagnosis of diffuse liver disease. The procedure is suitable to be performed safely on an outpatient basis.