ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group.

BACKGROUND: Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date. METHODS: This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire. RESULTS: Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. CONCLUSION: The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Sporadic aggressive fibromatosis of the colon and abdominal wall in an emergency setting.

AIM: Our aim is to present an utterly unique case of sporadic aggressive fibromatosis (AF), infiltrating both the abdominal wall and the colon; and especially, to discuss the usefulness of porcine dermal meshes for the reconstruction of a large parietal gap in contaminated surgery and in an emergency setting. CASE EXPERIENCE: We report the case of a 40 years old woman affected by sporadic AF, involving both the anterior abdominal wall and the colon, with an effective intestinal stricture. The surgery consisted in removing "en bloc" the portions of the colon and abdominal wall affected by fibromatosis, with no residual tumor (R0), that left an important parietal gap. A biological prosthesis of cross-linked acellular porcine dermal collagen (APDC) has been used for the contextual reconstruction of the abdominal wall, sutured inlay by a double line of non absorbable stitches. No complications have been observed. After one year follow up, there is no tumour recurrence and the abdominal wall has fully consolidated. DISCUSSION: The peculiar problems arising about differential diagnosis, therapeutic indications and reconstructive surgical procedures are discussed, especially with regard to prosthetic implants in contaminated surgery and to cross-linked APDC prosthesis. CONCLUSIONS: Complete surgical removal is the first line treatment in sporadic AF, whenever feasible. In the reported case, an R0 resection was obtained at the cost of a wide parietal gap. According to our experience, cross-linked APDC is effective for the prosthetic reconstruction of abdominal wall in contaminated surgery and in an emergency setting. KEY WORDS: Abdominal wall, Aggressive fibromatosis, Desmoid tumor, Prosthetic devices, Reconstructive surgical procedures, desmoid tumor.

Staples versus subcuticular closure in cervicotomy incisions.

Collar transverse incision is the typical surgical access for operations on thyroid and parathyroids. The cosmetic outcome resulting from its closure is of paramount importance given its anatomical exposure. The traditional methods of closure include metal clips, subcuticular stitch and glue. In this study we evaluated the cosmetic results on 10 patients who had their cervicotomy wound closed with clips comparing it to a second group of 10 patients who had the same incision closed with subcuticular stitch. The cosmetic outcome was evaluated with a questionnaire answered by the patients, by the operating surgeon and by a surgical nurse who was blinded to the technique used. The results of the questionnaire were grossly similar with no differences in the two groups. Only two complications were recorded in the subcuticular group. Both the techniques associate to similar cosmetic outcome, and the choice between the two should be left to the surgeon's personal preference.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies.

BACKGROUND: The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS: We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS: Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS: Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Meta-analysis of randomized trials on the efficacy of vascular closure devices after diagnostic angiography and angioplasty.

BACKGROUND: The aim of this meta-analysis was to evaluate the safety and efficacy of vascular closure devices (VCDs). METHODS: This meta-analysis was performed in accordance with the Cochrane Handbook for Systematic Reviews. RESULTS: The literature search yielded 31 prospective, randomized studies including 7,528 patients who were randomized to VCDs or manual/mechanical compression after diagnostic angiography and/or endovascular procedures. Most of these studies have excluded patients at high risk of puncture site complications. Meta-analysis showed similar results in the study groups in terms of groin hematoma, bleeding, pseudoaneurysm, and blood transfusion. Lower limb ischemia and other arterial ischemic complications (0.3% vs 0%, P = .07) as well as need of surgery for vascular complications (0.7% vs 0.4%, P = .10) were somewhat more frequent with arterial puncture closure devices. The incidence of groin infection was significantly more frequent with VCDs (0.6% vs 0.2%, P = .02). The use of VCD was uniformly associated with a significantly shorter time to hemostasis. Such differences where more evident in patients undergoing percutaneous coronary intervention, whereas these methods were associated with similar rates of adverse events among patients undergoing diagnostic coronary angiography. CONCLUSIONS: The use of VCDs is associated with a significantly shorter time to hemostasis and thus may shorten recovery. However, the use of VCDs is associated with a somewhat increased risk of infection, lower limb ischemia/arterial stenosis/device entrapment in the artery, and need of vascular surgery for arterial complications. Further studies are needed to get more conclusive results, particularly in patients at high risk of femoral puncture-related complications.