A prospective randomized study comparing laparoscopic transabdominal preperitoneal (TAPP) versus Lichtenstein repair for bilateral inguinal hernias.

BACKGROUND: In literature, only a few studies have prospectively compared the results of laparoscopic with open inguinal hernia repair yet none have compared bilateral inguinal hernia repair. The aim of this study is to compare the open Lichtenstein repair (OLR) with laparoscopic trans-abdominal preperitoneal (TAPP) repair in patients undergoing surgery for bilateral inguinal hernia. METHODS: Patients were prospectively randomized between March 2013 and March 2015. Outcome parameters included hospital stay, operation time, postoperative complications, immediate postoperative pain and chronic pain, recurrence and quality of life. RESULTS: Sixty-one patients underwent TAPP repair and 73 underwent OLR. TAPP procedure had less early post-operative pain up to 7 days from surgery (p = 0.003), a shorter length of hospital stay (p = 0.001), less postoperative complications (p = 0.012) and less chronic pain (0.04) when compared with the OLR approach. CONCLUSIONS: TAPP procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications.

A comparative study of neoadjuvant treatment with gemcitabine plus nab-paclitaxel versus surgery first for pancreatic adenocarcinoma.

INTRODUCTION: Neoadjuvant treatment has been reported to prolong survival in patients with potentially resectable pancreatic adenocarcinoma (PA). However, there are currently limited clinical results available using nab-paclitaxel and gemcitabine in PA. This paper compares the oncological results of patients affected by potentially resectable PA who underwent surgery first (SF) versus surgery following neoadjuvant treatment (NAT). METHODS: This is an observational, comparative study whereby data were abstracted from a prospective database of patients affected by PA from 2007 to 2016. RESULTS: We included a total of 81 patients (36 SF and 45 NAT) which resulted in being preoperatively similar. Among the NAT patients, treatment was well tolerated and the resection rate was 68.8% (31/45 patients). There was a trend towards a higher R1 resection rate in the SF group compared with the NAT (13.8% vs 3.2%; p = 0.1). Median overall survival in the resected NAT group was higher (30.6 vs 22.1 months; p = 0.04). In the borderline resectable group, overall survival was found to be four times higher compared with SF (43.6 versus 13.5 months; p = 0.001). CONCLUSIONS: These data suggest that neoadjuvant treatment with gemcitabine/nab-paclitaxel is a safe and effective option for potentially resectable PA compared with the SF approach.

Robotic versus laparoscopic distal pancreatectomy: A comparative study of clinical outcomes and costs analysis.

BACKGROUND: The robotic surgery cost presents a critical issue which has not been well addressed yet. This study aims to compare the clinical outcomes and cost differences of robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP). METHODS: Data were abstracted prospectively from 2011 to 2017. An independent company performed the financial analysis. RESULTS: A total of 28 RDP and 26 LDP were included. The mean operative time was significantly lower in the LDP (294 vs 241 min; p = 0.02). The main intra and post-operative data were similar, except for the conversion rate (RDP: 3.6% vs LDP: 19.2%; p = 0.04) and hospital stay (RDP: 8.9 vs LDP 13.1 days; p = 0.04). The mean total costs were similar in both groups (RDP: 9198.64 € vs LDP: 9399.74 €; p > 0.5). CONCLUSIONS: RDP showed lower conversion rate and shorter hospital stay than LDP at the price of longer operative time. RDP is financially comparable to LDP.

Ex Situ Hepatectomy and Liver Autotransplantation for Cholangiocarcinoma.

BACKGROUND: Hepatic resection of tumors invading the retrohepatic vena cava and hepatic veins are a challenge for surgeons, who consider them unresectable most of the time.1 , 2 Ex situ hepatectomy and liver autotransplantation has developed to improve resectability of these malignancies.3,4 METHODS: The patient was a 51-year-old man who had jaundice secondary to a intrahepatic cholangiocarcinoma 7 cm in diameter in the right lobe of the liver and the caudate lobe. A volumetric scan showed a future liver remnant (segments 2 and 3) not sufficient according to the body weight. The patient was considered to be unresectable by conventional resection due to the critical invasion to the retrohepatic vena cava together with the three hepatic veins. Therefore, an ex vivo extended right hepatectomy and autotransplantation were indicated. RESULTS: The patient underwent biliary decompression through a percutaneous transhepatic catheter and right portal vein embolization for left lobe hypertrophy. During the surgery, the liver was removed with the retrohepatic vena cava, which was replaced by a prosthetic graft without a veno-venous bypass. Ex vivo extended right hepatectomy was performed, and a prosthetic graft was used to replace the vena cava where the remaining left hepatic vein was anastomosed. The surgery duration was 9 h, and the anhepatic time was 4.5 h. The postoperative hospital stay was 19 days, and at this writing, 3 years later, the patient is disease-free. CONCLUSION: Ex vivo hepatectomy without veno-venous bypass should be considered a valid therapeutic option for selected patients with cholangiocarcinoma invading the retrohepatic vena cava.

Laparoscopic ventral rectopexy for internal rectal prolapse using biological mesh: postoperative and short-term functional results.

BACKGROUND: Laparoscopic ventral mesh rectopexy is a novel procedure to correct internal and external rectal prolapse. Several authors have shown that this approach is safe and improves obstructive defaecation symptoms and faecal incontinence, without inducing new-onset constipation, possible after posterior rectopexy. Over the last decade, as for other procedures, biological meshes are used to correct pelvic floor disorders. Literature data are scant. In this study, we present our experience with this procedure using biological mesh. PATIENTS AND METHODS: Prospectively collected data on laparoscopic ventral mesh rectopexy for internal rectal prolapse were analysed. All patients underwent preoperative evaluation with defaecating proctography and/or pelvic dynamic MRI, full colonoscopy, anal physiology studies and endo-anal ultrasound. End-points were to evaluate surgical complications and functional results of this technique such as changes in bowel function (Wexner Constipation Score and Faecal Incontinence Severity Index) at 3 and 6 months. Analysis was performed using Mann-Whitney U test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p test). RESULTS: Thirty-four consecutive patients underwent laparoscopic ventral mesh rectopexy (median age 59, range 25-78 years, mean follow-up was 12 months). Twenty-eight patients (82%) had a constipation score ≥ 5, while 14 (41%) a FISI score ≥ 10. Nine patients (26%) had mixed obstructed defaecation and faecal incontinence. One patient required conversion to open (3%). Median length of stay was 2 days. Overall complication rate was 23.5%. Preoperative constipation (median Wexner score 15) and faecal incontinence (median FISI score 12) improved significantly at 3 months (Wexner 5, FISI 5, both p < 0.001). Two patients experienced prolapse persistence or recurrence. No patients had function worsening or complained of sexual dysfunction. CONCLUSIONS: Laparoscopic ventral mesh rectopexy using biological mesh for internal rectal prolapse is safe and effective in ameliorating symptoms of obstructed defaecation and faecal incontinence.

Radiofrequency versus conventional diathermy Milligan-Morgan hemorrhoidectomy: a prospective, randomized study.

BACKGROUND: In the past decade, several new surgical tools have revived the hope for an improved technique to treat radically hemorrhoids with less postoperative pain. Among these radiofrequency (RF), excisional surgery seems to be safe, fast, and accompanied by less postoperative pain. The aim of this study was to evaluate and compare RF (ligasure TM) to conventional diathermy Milligan-Morgan hemorrhoidectomy (MMH). PATIENTS AND METHODS: Between January 2003 and July 2009, 210 symptomatic patients were randomized to undergo RF (118 patients) or diathermy MMH (92 patients). Mean follow-up was 39 ± 16 months. Clinical outcome was assessed by validated questionnaire on postoperative symptoms and satisfaction. Primary endpoints were pain and wound healing. Secondary endpoints were operative time, early and late complications (including recurrences), and patient satisfaction. Data was analyzed using chi-squared test and Fisher's exact test. RESULTS: Despite postoperative pain was less after RF, this difference was significant only for severe pain (expressed as VAS score >7). Significant differences were observed in terms of wound healing. The two techniques were similar in terms of early and late complications. CONCLUSIONS: RF hemorrhoidectomy is followed by reduced severe pain and better wound healing. However, in our experience, this is not followed by earlier return to daily activities.