Left Hypochondrium or Transumbilical Single-Incision Laparoscopic Sleeve Gastrectomy for the Treatment of Severe Obesity: Surgical Technique and Results of a Tertiary Referral Bariatric Center.

BACKGROUND: Technical aspects of single-incision laparoscopic sleeve gastrectomy (SILSG) vary depending on surgeon's experience and availability of surgical equipment. We have performed more than 3000 SILSGs using standardized technique with left hypochondrium or transumbilical access. The aim of this study is to describe the SILSG technique in a stepwise manner providing technical tips and pitfalls for a left hypochondrium or transumbilical approach and report results of SILSG experience in a tertiary referral bariatric center. METHODS: A detailed description of left hypochondrium and transumbilical SILSG is provided. Data from all consecutive patients who underwent SILSG between August 2010 and August 2017 were prospectively collected and retrospectively analyzed and reported. RESULTS: One thousand eight hundred patients underwent SILSG, from which 384 (21.3%) using a transumbilical approach. Mean age was 42.3 years, median BMI 45.3 kg/m2, and median operative time 88 min. An additional port was required in 89 patients (4.9%). Postoperative mortality and morbidity rates were 0.05% and 7.5%, respectively. Relaparoscopy and/or endoscopic treatment were required for intra-abdominal bleeding in 27 patients (1.5%) and staple-line leakage in 35 patients (1.9%). Mean excess weight losses were 71.1%, 73.7%, and 70.4% at 1, 2, and 4 years after SILSG, respectively. Two years after SILSG, sustained statistical significant remission of major obesity-related comorbidities was noted. Incisional hernia occurred in 39 patients (2.1%). CONCLUSIONS: The use of specific instruments allows standardization of left hypochondrium SILSG, which can be routinely performed for the treatment of severe obesity. Transumbilical approach for SILSG should be reserved for well-selected patients and experienced bariatric surgeons.

Investigation of intraoperative factors associated with postoperative pancreatic fistula following laparoscopic left pancreatectomy with stapled closure: a video review-based analysis : Video-review for predictors of pancreatic leak.

INTRODUCTION: Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) remains the most frequent complication, potential precursor of more serious events, and mechanisms behind POPF development are not clear. Primary aim of the current study is to investigate correlations between patients' characteristics, including technical intraoperative data assessed by retrospective video review of laparoscopic DP (L-PD), and development of clinically relevant (CR-)POPF and major complication. METHODS: Patients undergoing L-DP whose surgery video was available for review were included in this study. Retrospective video review, performed by two surgeons blinded for postoperative outcomes, was focused on pancreatic neck transection and identification of pancreatic capsule disruption (PCD)/staple line bleeding (SLB). Correlation between clinical, demographic, and intraoperative factors and CR-POPF/major complications and assessment of factors associated with PCD and SLB were investigated. RESULTS: Of 41 L-DP performed at our institution (June 2015-June 2020) using a triple-row stapler (EndoGIA™ Reloads with Tri-Staple™), surgery video was available for 38 patients [men/women, 13/25; median age (range) 62 (25-84) years; median BMI (range) 24 (17-42)]. PCD and SLB occurred in 15(39%) and 19(50%) patients and were concomitant in 9(24%). CR-POPF and major complications occurred in 8(21%) and 12(31%) patients, respectively. PCD, SLB, and PCD + SLB rates were significantly higher among patients with CR-POPF, compared to patients without (all p < 0.05). Among patients with PCD, pancreatic thickness at pancreatic transection site was higher (19 mm), compared to non-PCD patients (13 mm, p < 0.001). A directly proportional relation between PCD, CR-POPF, and major complication rate and pancreatic thickness was confirmed by ROC analysis (AUC = 0.949, 0.798, and 0.740, respectively). CONCLUSION: PCD and SLB close to the staple line detected by retrospective video-review are intraoperatively detectable indicators of severe pancreatic traumatism and a potential precursors of CR-POPF following L-PD. Given the strict correlation between PCD and pancreatic thickness, alternative techniques to stapled closure for pancreatic transection may be recommended for patients with a thick pancreas and modification in postoperative care may be considered in patients with PCD/SLB.

Extracorporeal versus intracorporeal anastomosis after laparoscopic right hemicolectomy: cost-effectiveness analysis.

AIM: The cost effectiveness of the laparoscopic right hemicolectomy is still debated, and the current literature does not allow to be drawn certain conclusion. Our study compared direct clinical costs and outcomes for laparoscopic right hemicolectomy with the two most used type of anastomosis, such as ExtraCorporeal Anastomosis (ECA) and IntraCorporeal Anastomosis (ICA). MATERIAL AND METHODS: In this retrospective study, all patients who underwent laparoscopic right hemicolectomy with intracorporeal and extracorporeal anastomosis between January 2016 and April 2018 were evaluated. Patients were divided into two groups according to the type of anastomosis: ECA or ICA. RESULTS: Thirty ECA and twenty-nine ICA patients were included in the study. Operative time was significantly longer in ICA group than ECA group (p < 0.001). No significant differences between the groups were seen in terms of timeto- first flatus, postoperative complications and re-admission rate. ICA group showed a shorter hospitalization (5 vs 6; p < 0.022). In the ICA group, considering only the surgical tools were more expensive than in ECA (1435.6 € vs 72 €). Nevertheless, the total cost of the two procedures in similar (14451.36 € in ECA group vs 14631.04 € in ICA group). CONCLUSION: ECA and ICA are comparable in terms of postoperative outcomes. ICA requires much more expensive charges, compared to a minor hospitalization. The ECA seems to be less expensive in terms of surgical supplies but the longer recovery determines an increase in the total cost resulting in a non-inferiority of one compared to the other technique. KEY WORDS: Cost-analysis, ExtraCorporeal Anastomosis, IntraCorporeal Anastomosis, Laparoscopy, Right Hemicolectomy.

The Health Care Providers' Perspectives on End-of-Life Patients' Sense of Dignity. A Comparison Among Four Different Professionals' Categories.

The studies on terminally ill patients' dignity as perceived by health care providers (HCPs) in palliative care are growing. The comparison of different HCPs' perspectives in particular is necessary to explore how HCPs perceive patients' dignity in order to promote reflection on this core issue. This study aimed to investigate the perspectives on end-of-life patients' sense of dignity among four different categories of professionals: nurse assistants, nurses, psychologists, and physicians. A sample of 306 HCPs completed the Patient Dignity Inventory-Italian Version (PDI-IT) adapted for them and an ad hoc semi-structured written interview. Their responses were then analyzed using frequencies of the answers to the PDI-IT, a multivariate analysis of variance, Pearson's correlation index, t tests, and content analysis. All HCPs scored the relevance to the dignity-related physical aspects highly, followed by the psychological distress. Nurse assistants and nurses provided higher scores on the psychological and existential and spiritual PDI subscales than the other HCP groups. The social sphere was evaluated as the least salient for the patients' sense of dignity. Physicians who attended a course on dignity considered the psychological and existential dignity dimensions more. Differences in role and expertise could lead to different HCPs' perspectives on dignity, while the multidisciplinary work could favor their aligning. Therefore, it is essential to encourage HCPs' communicative exchange and reflective awareness through training, i.e., courses, seminars, and focus groups. These developments could promote increasingly adequate patient-centered care.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review.

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Antimeningococcal and antipneumococcal vaccination determinants: a European systematic literature review.

BACKGROUND: ESCULAPIO is a multicenter project, funded by the Italian Centre for Disease Prevention and Control, aimed at implementing communication strategies to improve vaccination knowledge and attitudes among different target populations. OBJECTIVE: The objective of the Sicilian research unit was, in the first phase, to identify, through systematic literature revision, which vaccination determinants play a role in the uptake of recommended vaccines included in the Italian Vaccination Plan. DESIGN: A systematic literature review was carried out on studies describing the determinants underlying pneumococcal and meningococcal vaccination uptake. The analysis was limited to papers published in English from 2000 to date. RESULTS: A total of 188 (meningococcal) and 731 (pneumococcal) papers were found. After selection by publication data, country (Europe), article type (original article), target population (healthy subjects), 7 (meningococcal) and 4 ( pneumococcal) manuscripts were finally included in the analysis. For meningococcal vaccination a better socioeconomic status is related to vaccination acceptance, whereas distance from immunization service is a negative determinant. For pneumococcal vaccination the determinants related to vaccination uptake are older parental age and a strong vaccine recommendation. Conversely, when the vaccine needs to be paid for, a refusal is more likely. CONCLUSIONS: Our results show that payment for vaccination is a major barrier and communication about meningococcal and pneumococcal vaccination should be targeted towards specific population groups, especially through the counseling activities by health professionals.

Intrauterine growth pattern and birthweight discordance in twin pregnancies: a retrospective study.

BACKGROUND: Twins, compared to singletons, have an increased risk of perinatal mortality and morbidity, due mainly to a higher prevalence of preterm birth and low birthweight. Intrauterine growth restriction (IUGR) is also common and can affect one or both fetuses. In some cases, however, one twin is much smaller than the other (growth discordance). Usually, high birthweight discordance is associated with increased perinatal morbidity. The aim of this study is to describe the epidemiological features of a population of twins at birth, with particular reference to the interpretation and clinical effects of birthweight discordance. METHODS: We evaluated retrospectively the clinical features of 70 infants born from twin pregnancies and assessed birthweight discordance in 31 pregnancies where both twins were followed at our institution. Discordance was treated both as a continuous and a categorical variable, using a cutoff of 18%. Possible relationships between birthweight discordance and other variables, such as maternal age, gestational age, birthweight percentile, number of SGA newborns in the pair, Hematocrit (Ht) discordance and neonatal anemia, prevalence of malformations, neonatal morbidity and death, were analyzed. RESULTS: In our cohort birthweight percentile decreased slightly with increasing gestational age. Birthweight discordance, on the contrary, increased slightly with the increase of gestational age.A high discordance is associated to the presence of one SGA twin, with the other AGA or LGA. In our population, all 6 pregnancies in which discordance exceeded 18% belonged to this category (one SGA twin).Ht discordance at birth is associated to the presence of neonatal anemia in a twin, but it is not significantly related to weight discordance.Finally, in our case history, weight discordance is not associated in any way with the prevalence of malformations, morbidity and mortality. CONCLUSIONS: Birthweight discordance is an important indicator of complications that act asymmetrically on the two fetuses, affecting intrauterine growth in one of them, and usually determining the birth of a SGA infant.Our case history shows a significant statistical association between pair discordance and IUGR in one of the twins, but we could not demonstrate any relationship between discordance and the prevalence of malformations, morbidity and mortality.