Comparison between three mini-sling surgical procedures and the traditional transobturator vaginal tape technique for female stress urinary incontinence.

OBJECTIVES: To compare mini-sling and traditional tension-free operations for female stress urinary incontinence. STUDY DESIGN: A systematic review of articles in the Literature published between 2002 and 2012, was conducted. A Pubmed search was performed. Primary outcomes were subjective and objective cure rates at 12 months comparing the three single-incision mini-slings techniques (TVT-Secur, MiniArc and Monarc systems) with the standard midurethral sling procedure TOT (Transobturator Vaginal Tape). Secondary outcomes included peri-operative (vaginal and/or bladder perforation, urine retention, urinary tract infection, bleeding, pain) and post-operative (mesh exposure, de novo urgency, and dyspareunia) complications. RESULTS: In term of objective cure rate at 12 month after surgery, it is evident that TOT at first, and MiniArc are the most effective procedures. The incidence of post-operative urgency and UTI was lower in TOT technique, while vaginal perforation was described in equal frequency both in TOT and in MiniArc procedures. The advantages of the three above described mini-invasive techniques seem to consist into lower cases of urinary retention, pain and bleeding. Furthermore, bladder perforation and bleeding are not described in the Literature for TVT-Secur and Monarc systems. CONCLUSIONS: Some single-incision slings look promising and as effective as conventional sub-urethral slings at short term evaluation. However, at this moment a clear statement in favor of the widespread use of single-incision slings cannot be made. More studies must define the efficacy of these techniques.

Mini-invasive tension-free surgery for female urinary incontinence.

The Authors describe the techniques they perform of prepubic, retropubic and transobturator mini-invasive anti-incontinence surgical procedures and point-out some technical details. The state of art and the results of these three main surgical procedure are compared and discussed. Data from the Literature have been reviewed in order to evaluate the efficacy of the techniques. A Medline search has been performed, and 65 relevant articles from 1996 to 2012 were selected. Literature showed similar cure rates among retropubic (71,4-91%), trans-oburator (77,3-95%) and prepubic (81-87,2%) anti-incontinence procedures. Cystoscopy was considered necessary in the retropubic, optional in transobturator and in the prepubic techniques. Intra-operative cough stress test was believed useful only in the retropubic and prepubic procedures. Obstruction symptoms prevailed in the retropubic, were rare in the transobturator and missing in the prepubic technique. Erosion rate was very low and similar for all the three techniques. Intra-operative vascular and perforating risks prevailed in the retropubic technique, due to the danger present in the retropubic space, whereas late infective complications overcame in the transobturator procedure. Severe complications in the prepubic procedure were not reported, but the procedure is performed only in few centers.

Laparoscopic-endoscopic rendez-vous resection of iuxta-cardial gastric GIST.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and they often require a surgical removal. Gastrointestinal stromal tumors can originate from any part of the gastrointestinal tract but gastric location is the most common. In the past the risk of rupture of pseudocapsula and peritoneal dissemination have discouraged surgeons from making a minimally invasive surgical treatment. Recently laparoscopic wedge resection has been proposed. Performance of this mini-invasive technique is however difficult in some gastric location of gastrointestinal stromal tumors, such as iuxta-cardial region. The Authors report and discuss a new technique they used to remove a gastrointestinal stromal tumor located just below the cardia, using a rendez-vous endoscopic and laparoscopic technique.

Laparoscopic treatment of mucinous adenocarcinoma of jejunum associated with celiac disease. Case report.

Mucinous adenocarcinoma of the small bowel is very rare, and only few cases have been described in the literature. Association of this tumor with celiac disease has never been published. The authors report a unique case of jejunal mucinous adenocarcinoma in which a concomitant celiac disease has been histologically recognized. The difficult diagnosis, the role of laparoscopic surgery and the relationship between small bowel tumors and celiac disease are discussed. A 49-year-old man presented with recurrent melena, nausea, vomiting and anemia. A stenosis of the jejunum was documented by means of CT scan and video capsule enteroscopy. A laparoscopy was scheduled. A tumor, found in the first jejunal loop, was removed by laparoscopic surgery. Histopathology revealed a rare mucinous adenocarcinoma associated with epithelial changes secondary to celiac disease. Although small bowel tumors are rare entity, in patients with celiac disease complaining of symptoms related to altered intestinal transit or occult bleeding, an appropriate work-up should be planned for diagnosis. Mucinous type intestinal adenocarcinoma, even if never published before, could be observed. Laparoscopic surgery is often essential for the diagnosis and treatment.

Polyp of the cecum. Laparoscopic-assisted polypectomy.

The Authors discuss on a laparoscopic-assisted approach for excision of a sessile villous adenomatous polyp of the cecum, unresectable by endoscopy. Because of the large implant of the polyp, endoscopic polypectomy was considered at high risk and a surgical laparoscopic procedure was scheduled for removal of the lesion. After right colon mobilization, an intraoperative endoscopy confirmed the location of th polyp in the posterior wall of the cecum, closed to the ileo-cecal valve. A small 10 cm laparotomy, through which the cecum was pulled out the abdominal cavity, was performed. Then, a minimal colotomy along the intestinal taenia was carried out to allow a safe and complete excision of the polyp. This laparoscopic approach differs from the other laparoscopic-assisted methods reported in the Literature since it provides at the same time the postoperative advantages associated with minimal access surgery and a safe oncological removal of the polyp with low risks of complications.

Major hepatectomy for perihilar cholangiocarcinoma in elderly patients: is it reasonable?

INTRODUCTION: We sought to evaluate the effect of age on postoperative outcomes among patients undergoing major liver surgery for perihilar cholangiocarcinoma (PHCC). METHODS: 77 patients were included. Patients were categorized into two groups: the "< 70-year-olds" group (n = 54) and the "≥ 70-year-olds" group (n = 23). RESULTS: Median LOS was 19 both for < 70-year-old group and ≥ 70-year-old group (P = 0.72). No differences in terms of severe complication were detected (44.4% Clavien-Dindo 3-4-5 in < 70-year-old group vs 47.8% in ≥ 70-year-old group, P = 0.60). Within 90 postoperative days, 11 patients died, 6 in < 70-year-old group (11.3%) and 5 in ≥ 70-year-old group (21.7%), P = 0.29. The median follow-up was 20 months. The death rate was 72.2% and 78.3% among patients < 70 years old and ≥ 70 years old. The OS at 2 and 5 years was significantly higher among the < 70 years old (57.0% and 27.7%) compared to the ≥ 70 years old (27.1% and 13.6%), P = 0.043. Adjusting for hypertension and Charlson comorbidity index in a multivariate analysis, the HR for age was 1.93 (95% CI 0.84-4.44), P = 0.12. Relapse occurred in 43 (81.1%) patients in the < 70-year-old group and in 19 (82.6%) patients in the ≥ 70-year-old group. DFS at 12, 24, and 36 months was, respectively, 59.6, 34.2, and 23.2 for the < 70 -year-old group and 32.5, 20.3, and 13.5 for the ≥ 70-year-old group (P = 0.26). Adjusting for hypertension and Charlson comorbidity index in a Cox model, the HR for age was 1.52 (95% CI 0.67-3.46), with P = 0.32. CONCLUSIONS: ≥ 70-year-old patients with PHCC can still be eligible for major liver resection with acceptable complication rates and should not be precluded a priori from a radical treatment.

Robot-Assisted Harvesting of Kidneys for Transplantation and Global Complications for the Donor.

INTRODUCTION: Robot-assisted kidney harvesting from living donors is feasible and safe. We report the results of a mono-centric experience relative to 98 consecutive robotic nephrectomies with emphasis on global donor complications. MATERIALS AND METHODS: This is a retrospective cohort study. Donors underwent robot-assisted kidney harvesting. The preferred kidney was the left one even in the presence of vascular anomalies. In the first cases we used a robotic hand-assisted technique, then the totally robotic technique, and finally the modified totally robot-assisted technique. Postoperative complications were ranked according to the five-grade Clavien-Dindo classification. RESULTS: Between November 2009 and November 2016, 98 living donors underwent nephrectomy. We experienced 14 complications. The 3 intraoperative ones (3.06%) were 1 pneumothorax and 2 acute bleedings, 1 of them requiring transfusion. The 11 postoperative complications (11.22%) were as follows: 5 wound seromas, 1 rhabdomyolisis (Clavien I), 1 paretic ileum, 1 anemia requiring transfusion, 1 hypertensive crisis (Clavien II), and 2 chylus collections drained by interventional radiologists (Clavien III). Transfusion rate was 2.1%; conversions, reoperations, and mortality were nil. No statistically significant difference was observed between the patients with complications and without in terms of gender, age, anatomical anomalies, body mass index (BMI), and learning curve. We observed a longer global operation length of time in patients with complications. CONCLUSION: Robotic assistance results in shorter and simpler learning curves for the harvesting of kidneys from living donors. It enables an easier and more efficient management of possible intraoperative complications. The rate of postoperative complications is comparable with the rate of complications encountered in traditional laparoscopic series with high numbers of harvestings.

Conservative surgical management of patients with bisphosphonate-related osteonecrosis of the jaws: a series of 120 patients.

We evaluated retrospectively the efficacy of local resection for patients who presented with bisphosphonate-related osteonecrosis of the jaw (BRONJ). We studied 120 subjects with who required local resection of 129 BRONJ lesions that had not responded to medical treatment. The primary outcomes were improvement of the clinical stage of BRONJ and resolution of disease, and the secondary outcome was the influence of the surgeon's experience on the healing of the lesions. Age, sex, underlying diseases, smoking, and coexisting conditions were recorded. Logistic regression analysis was used to isolate factors that could potentially affect the outcome. Most of the lesions (n=107, 84%) improved postoperatively, 20 showed no change, and one got worse. One patient died. Stratification indicated complete healing and total resolution of disease for all 26 stage I lesions, improvement for 67 of the 77 stage II lesions, and for 14 of the 25 stage III lesions. The disease resolved in 67 of the 69 stage II lesions, and 14 of the stage III cases. Logistic regression indicated that smoking and the stage of disease could affect the outcome. Analysis of the surgeons' learning curve showed that performance improved significantly over time. Complete healing after local resection increased from 40% to 80% over a period of eight years (p<0.001). We conclude that local resection may be the treatment of choice in BRONJ stages I and II. Stage III might be better treated with either resection or clinical monitoring according to the condition of the patient.

Dual Kidney Transplantation: Evaluation of Recipient Selection Criteria at Niguarda Hospital.

BACKGROUND: Dual kidney transplantation (DKT) is a largely accepted strategy to enlarge the donor pool. Niguarda Hospital started this program in December 2010, and 38 DKT have been performed. In our series, we included recipients older than those in the other series published in literature. The aim of this study was to know if our recipient selection criteria for DKT are safe. METHODS: We reviewed our data base of DKT and analyzed recipients' medical history, surgical technique, post-operative complications, graft survival, morbidity, and mortality. We then compared our results with the literature. RESULTS: From December 2010 to April 2015, 38 DKT were performed in Niguarda Hospital. Delayed graft function was present in 21 recipients. Explantation of both kidneys was performed in 1 patient and explantation of 1 kidney in 6 patients. Post-operative complications were present in 8 patients. Five patients returned to hemodialysis after DKT. One recipient died of medical post-operative sepsis. The mean follow-up was 24 months. Graft survival and patient survival were 86.84% and 97.93%, respectively. Compared with the literature, our series had similar mortality and morbidity rates, even if recipients' age was higher than in other series. CONCLUSIONS: The strategy of DKT allocation in elderly recipients is safe. Further studies have to be performed to optimized selection of the recipients for DKT not to disadvantage younger patients in the transplant waiting list and to improve the technique of organ evaluation and preservation to refine graft allocation.

Do Older Liver Grafts Have Worse Survival? The Niguarda Experience.

BACKGROUND: Elderly donor livers are thought to be marginal graft. In the present study, we aimed to identify an age threshold to consider a graft as elderly to identify the trend (if any) of the donor age in our series and to identify an efficient allocation criteria for elderly grafts. METHODS: We reviewed in a retrospective manner our series of 1520 liver transplants, comparing graft survival under and over a certain age. On the basis of the results of this analysis, we identified a threshold of 70 years to define a graft as old. The donor age trend analysis showed an increasing rate of transplants from elderly donors. RESULTS: To identify efficient allocation criteria for elderly graft, we stratified the series by the disease of the recipient: 556 patients underwent transplants for hepatocellular carcinoma (HCC+ group) and 964 for other diseases (HCC- group). Two hundred twenty-one patients of 556 of the HCC+ group were hepatitis c virus (HCV) negative (HCC+/HCV- group), and 312 of 964 of the HCC- group were HCV positive (HCC-/HCV+). The survival analysis showed no significant differences in comparing the outcome for elderly and young grafts in the HCC+ (P = .135) and HCC- (P = .055) groups. CONCLUSIONS: When comparing the survival of old and young livers in the HCC+/HCV- group, the elderly livers appear to have a better outcome (P = .05); on the other hand, the same analysis in the HCC-/HCV+ group shows a worse outcome for old-aged grafts (P = .026). Therefore, the present study suggests that elderly livers should be allocated to hepatocellular carcinoma (HCC) patients and should be avoided in HCV+ recipients.

Risk factors influencing BRONJ staging in patients receiving intravenous bisphosphonates: a multivariate analysis.

The objective of this study was to determine, retrospectively, the influence of various risk factors on the staging of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in a population attending a department of dentistry and oral surgery in Italy. Data were collected from the electronic and paper medical records of 90 patients receiving intravenous bisphosphonates. Two experienced and calibrated examiners used the American Association of Oral and Maxillofacial Surgeons updated 2009 classification to record the stage of BRONJ lesions. Multivariate ordinal logistic regression was performed to determine individual risk factors negatively affecting BRONJ staging. The factors associated with a worse BRONJ staging were high bisphosphonate cumulative dose (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.02-2.82; P=0.04), smoking (OR 1.80, 95% CI 1.03-2.80; P=0.04), steroid intake (OR 1.70, 95% CI 1.00-2.87; P=0.05), and a maxillary location of the lesion (OR 3.50, 95% CI 1.81-6.77; P<0.01). Tooth extraction was the event that most negatively influenced BRONJ staging (OR 1.60, 95% CI 1.00-2.81; P=0.05), in comparison to other events such as prosthetic trauma, implant treatment, oro-dental infection, and periodontal disease. Certain clinical and medical risk factors may determine a more severe staging of BRONJ lesions. Future studies are necessary to confirm these findings.

The WHO-UNDP epidemiological study on the health effects of exposure to organophosphorus pesticides.

A multinational epidemiological study on the neurotoxic effects of long-term, low-level exposure to organophosphorus pesticides (OPs) is being supported in ten European countries by the United Nations Development Programme (UNDP) jointly with the World Health Organization (WHO) Regional Office for Europe. The protocol developed for the study is directed at the assessment of OP exposure and absorption, abnormal neurological findings, and behavioral changes in both agricultural and industrial workers. The biological monitoring tests adopted in the study have been standardized and submitted to quality assurance programmes.

Ultrasound therapy of chronic arm lymphedema after surgical treatment of breast cancer.

The treatment of chronic arm lymphedema following axillary dissection for breast cancer is still a therapeutic challenge. To examine other treatment options, we undertook a pilot study on the efficacy of ultrasound therapy (UST) in management of these patients. Fifty patients with post-surgical arm lymphedema and without regional irradiation underwent ultrasound treatment (2 cycles at 4 month intervals) and the results were compared up to 1 year with 100 other patients treated by standardized mechanical pressure therapy (MPT) using a pneumatic pump. In this report we evaluate 96 patients who have been followed after 1 year, 31 of whom belong to UST group and 65 to the MPT group. UST did not show a statistically significant difference in whole arm reduction of lymphedema although there was initially a greater reduction in size after the first 4 months of treatment. The addition of an elastic sleeve did not improve lymphedema in either group. Advantages of UST were an overall shorter length of treatment, a tendency to greater softening of the arm, patient satisfaction by avoidance of an uncomfortable and constrictive device and better relief of osteomyofascial pain, greater scapulohumeral motion, and less intercostobrachial pain-dysesthesia.

Programmes and activities of the International Centre for Pesticide Safety.

The International Centre for Pesticide Safety (ICPS) is a research unit of the National Health Service created by the Government of the Region of Lombardy at the proposal of the World Health Organization-Regional Office for Europe, in cooperation with the University of Milan, and in agreement with the Italian Ministry of Health. ICPS operates in the following areas of activity: information and documentation on pesticide toxicity to man and environment, epidemiological, toxicological and clinical research on effects of pesticides in man; training and education of personnel in public health, assessment of environmental and health impact of pesticides by means of Geographical Information Systems, laboratory research for development and standardisation of methods for residue measurement in environmental and biological media. ICPS is also a centre of international meetings and continuing education courses. A number of projects carried out or underway at ICPS are briefly described in this paper.

[Major surgical complications after 73 consecutive liver transplantations]. / Complications chirurgicales majeures après 73 transplantations hépatiques consécutives.

In order to evaluate the incidence of postoperative surgical complications requiring additional surgery, we report 73 consecutive liver orthotopic transplantations performed in 60 patients from June 1983 through June 1989. Transplantations were performed in 54 adults and 6 children for the following reasons: postnecrotic cirrhosis in 31, biliary diseases in 16, hepatobiliary malignancy in 7; Wilson's diseases in 3 and fulminant hepatitis in 3. Surgical complications requiring additional surgery occurred in 35 (58%) patients with 53 operations. Twenty-two patients (36%) had postoperative bleeding complications, 5 (8%) biliary complications, one had a late artery thrombosis and 16 (26%) had miscellaneous complications. The latter group included 6 abdominal hernias, 3 bowel perforations, 2 bowel obstructions, 2 cases of pneumothorax, 2 cases of chylous ascitis, one liver necrosis, one hepatic artery kinking, one peritonitis and one cardiac tamponade. The incidence of surgical complications was not significantly different in patients who underwent retransplantation as compared to those who had a single transplantation. We did not find a significant difference in surgical complication rate according to the preoperative liver disease. In comparison with the literature, in our series, we had a higher rate of abdominal hernia but a lower rate of biliary complications.

The International Centre for Pesticide Safety.

The International Centre for Pesticide Safety (ICPS) was inaugurated in March 1990. Coordinated by the World Health Organization (WHO) and in collaboration with research and university institutions, the Centre operates in the following areas of activity: information and documentation on pesticide toxicity; epidemiological, toxicological and clinical research; training and education; laboratory research. ICPS is also a centre of meetings and courses on permanent education. This paper reports on the activities carried out so far and on the future programmes of ICPS.

Split-liver full-left full-right: proposal for an operative protocol.

INTRODUCTION: Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor. OBJECTIVE: The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure. MATERIALS AND METHODS: A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined. RESULTS: The donor characteristics should be consistent with the following: age≤55 years; weight≥70 kg; body mass index<28 kg/m2; intensive care unit stay<7 days; sodium level<160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis<20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs. CONCLUSIONS: The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria.

Laparoscopic splenectomy in patients with hereditary spherocytosis: report on 12 consecutive cases.

Hereditary spherocytosis is an inherited hemolytic anemia caused by a deficiency in erythrocyte membrane proteins. Removal of the spleen may reduce the intra-splenic hemolytic process of the disease and, therefore, may correct the anemia. Furthermore, it seems to decrease the levels of serum bilirubin, thus reducing the formation of gallbladder stones. Indications and timing of splenectomy, however, are still debated. Twelve patients with severe hereditary spherocytosis operated on with laparoscopic splenectomy were retrospectively reviewed. Median age at diagnosis was 13.8 years (range 8-25 years). Male to female ratio was 5/7. Indications for laparoscopic removal of the spleen included anemia unresponsive to iron supplementation in eight patients (66.6 %) with increase need for red cells transfusions, and jaundice with symptoms related to cholelitiasis in four patients (33.3 %). Laparoscopic splenectomy was associated in four cases to laparoscopic cholecystectomy. Mean operative time was 50 min (range 40-75 min) with no conversion to open surgery. Mean hospital stay ranged from 3 to 7 days. In a 16-month follow-up, no complications were recorded and a persistent correction of anemia was observed. With the advent of laparoscopic surgery, splenectomy has been performed by this mini-invasive approach in referral centers. Laparoscopic splenectomy is an effective technique, when performed in patients with hereditary spherocytosis. Low complication rate and persistent correction of the hematologic disorders can be expected after the laparoscopic splenectomy, provided that a proper technique is performed and an experienced surgical team is available.