Current Management of Acute Severe Ulcerative Colitis: New Insights on the Surgical Approaches.

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity. Despite recent advances in medical IBD therapy, colectomy rates for ASUC remain high. A scoping review of published articles on ASUC was performed. We collected data, such as general information of the disease, diagnosis and initial assessment, and available medical and surgical treatments focusing on technical aspects of surgical approaches. The most relevant articles were considered in this scoping review. The management of ASUC is challenging; currently, personalized treatment for it is unavailable. Sequential medical therapy should be administrated, preferably in high-volume IBD centers with close patient monitoring and indication for surgery in those cases with persistent symptoms despite medical treatment, complications, and clinical worsening. A total colectomy with end ileostomy is typically performed in the acute setting. Managing rectal stump is challenging, and all individual and technical aspects should be considered. Conversely, when performing elective colectomy for ASUC, a staged surgical procedure is usually preferred, thus optimizing the patients' status preoperatively and minimizing postoperative complications. The minimally invasive approach should be selected whenever technically feasible. Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA) has shown similar outcomes in terms of safety and postoperative morbidity. The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) is a recent technique for creating an ileal pouch-anal anastomosis via a transanal route. Early experiences suggest comparable short- and medium-term functional results of the transanal technique to those of traditional approaches. However, there is a need for additional comparative outcomes data and a better understanding of the ideal training and implementation pathways for this procedure. This manuscript predominantly explores the surgical treatment of ASUC. Additionally, it provides an overview of currently available medical treatment options that the surgeon should reasonably consider in a multidisciplinary setting.

The multidisciplinary management of locally advanced rectal cancer.

INTRODUCTION: The classic paradigm for the management of locally advanced rectal cancer (LARC) consists of (chemo)radiotherapy (C)RT), total mesorectal excision, and adjuvant chemotherapy (CHT). At present, due to the high rate of distant metastasis (up to 30%), the total neoadjuvant therapy (TNT) with the administration of systemic CHT in the neoadjuvant setting has gained acceptance as standard of care.Our aim is to critically review the current literature on LARC management and summarize the different approaches recently proposed to improve clinical outcomes. It represents a starting step to develop an effective strategy that ultimately could harmonize the standard of care in daily clinical practice. AREAS COVERED: Studies reporting the impact of TNT approaches were deemed eligible. De-escalation strategies, including non-operative management (NOM) after TNT, as well as RT omission or systemic therapy alone, were also investigated. EXPERT OPINION: The year 2020 has seen promising new data from randomized phase III trials in the field of LARC management. Nowadays, TNT strategy has been accepted as the primary treatment for LARC. The role of de-escalation strategies is still unknown. The goal is to achieve better survival outcomes with improving quality of life. Only selected patients are likely to benefit from NOM or immunotherapy alone.

Palliative Surgery or Metallic Stent Positioning for Advanced Gastric Cancer: Differences in QOL.

BACKGROUND AND OBJECTIVES: Twenty percent of the patients affected with stage IV antropyloric stomach cancer are hospitalized with a gastric outlet obstruction syndrome (GOOS) requiring its resolution to improve the quality of life (QoL). We present our preliminary short- and mid-term results regarding the influence of endoscopic placement of self-expandable metal stent (SEMS) or open stomach-partitioning gastrojejunostomy in QoL. MATERIALS AND METHODS: In this prospective randomized longitudinal cohort trial, we randomly assigned 27 patients affected with stage IV antropyloric stomach cancer into two groups: Group 1 (13 patients) who underwent SEMS positioning and Group 2 (14 patients) in whom open stomach-partitioning gastrojejunostomy was performed. The Karnofsky performance scale and QoL assessment using the EQ-5D-5L™ questionnaire was administered before treatment and thereafter at 1, 3, and 6 months. Results: At 1-month, index values showed a statistically significant deterioration of the QoL in patients of Group 2 when compared to those of Group 1 (p = 0.004; CI: 0.04 to 0.21). No differences among the groups were recorded at 3-month; whereas, at 6-month, the index values showed a statistically significant deterioration of the QoL in patients of Group 1 (p = 0.009; CI: -0.25 to -0.043). CONCLUSIONS: Early QoL of patients affected with stage IV antropyloric cancer and symptoms of GOOS is significantly better in patients treated with SEMS positioning but at 6-month the QoL significantly decrease in this group of patients. We explained the reasons of this fluctuation with the higher risk of re-hospital admission in the SEMS group.

Colon or Rectal Stent Positioning for Advanced Cancer Influences Quality of Life: A Critical Point of View.

BACKGROUND/AIM: Endoluminal self-expanding metallic stents (SEMS) may overcome the risk of mortality and morbidity of acute intestinal obstruction because of stage IV colon (CC) or rectal (RC) cancer. We evaluated the QoL in these groups of patients. PATIENTS AND METHODS: Forty-eight patients were enrolled in a prospective longitudinal cohort single-center trial to undergo SEMS positioning. Twenty-five patients had a CC and 23 RC. Karnofsky performance scale, Visual Analogue Scale and the EQ-5D- 5L™ questionnaire were administered before treatment and at 1, 3 and 6 months. RESULTS: Harmonized to the Italian population, the index values showed a statistically significant deterioration of the QoL in patients with RC when compared to those with CC at 1-, 3- and 6-months (1 month: p=0.001; 3- month: p=0.001; 6-month: p=0.045). Similarly, Visual Analogue Scale showed variations at 1- (p=0.008), 3- (p=0.001) and 6-months (p=0.020). Rectal stent deployment was the only independent predictor for a worse QoL in all domains (p<0.017; OR=0.196; 95%CI=0.51-0.749). CONCLUSION: Patients affected with stage IV CC had a better QoL after SEMS placement when compared to those affected with RC. The persistency of the primary tumor at the rectal level, even if irradiated, might negatively affect QoL.

Laparoscopic lavage and drainage for Hinchey III diverticulitis: review of technical aspects.

The surgical treatment for patients with generalized peritonitis complicating sigmoid diverticulitis is currently debated; particularly in case of diffuse purulent contamination (Hinchey 3). Laparoscopic lavage and drainage (LLD) has been proposed by some authors as a safe and effective alternative to single- or multi-stage resective surgery. However, among all the different studies on LLD, there is no uniformity in terms of surgical technique adopted and data show significant differences in postoperative outcomes. Aim of this review was to analyze the differences and similarities among the authors in terms of application, surgical technique and outcomes of LLD in Hinchey 3 patients. A bibliographical research was performed by referring to PubMed and Cochrane. "Purulent peritonitis", "Hinchey 3 diverticulitis", "acute diverticulitis", "colonic perforation" and "complicated diverticulitis" were used as key words. Twenty-eight papers were selected, excluding meta-analysis, reviews and case reports with a very small number of patients. The aim of this review was to establish how LLD should be done, suggesting important technical tricks. We found agreement in terms of indications, preoperative management, ports' positioning, antibiotics, enteral feeding and drain management. On the contrast, different statements regarding indications, adhesiolysis and management of colonic hole and failure of laparoscopic lavage are reported. A widespread diffusion of LLD and standardization of its technique are impossible because of data heterogeneity and selection bias in the limited RCTs. It is necessary to wait for long terms results from randomized clinical trials (RCTs) in progress to establish the efficacy and safety of this technique. More importantly, an increased number of highly skilled and dedicated colorectal laparoscopic surgeons are required to standardized the procedure.

Day case laparoscopic cholecystectomy: Safety and feasibility in obese patients.

INTRODUCTION: Day-case laparoscopic cholecystectomy (DCLC) is not universally adopted and its use is limited to patients selected by non-standardized criteria. Since laparoscopic cholecystectomy is considered technically more difficult in obese patients, a high body mass index (BMI) is often considered an exclusion criterion for DCLC. The aim of this research is to define the feasibility and safety of day case laparoscopic cholecystectomy in obese patients. PRESENTATION OF CASE: Data from 730 consecutive patients preoperatively considered suitable for DCLC were analysed. BMI was not considered as parameter of selection and patients were divided in two groups (Obese, 294; Non-obese, 436) according to a BMI ≥ 30 or < 30 kg/m2, respectively. Outcomes measured were morbidity, open conversion rates, hospitalization rates, length of hospital stay and readmission. Overall morbidity and open conversion rates were similar in both groups. No significant differences were observed among the two groups in terms of hospitalization rates (p 0.0533), early complications (p 0.2536), length of hospital stay (p 0.3780) and readmission rates (p 0.4286). DISCUSSION: Day case laparoscopic cholecystectomy is a widely used surgical technique despite not routinely used in every health system. However, many factors related to the patient and procedure, as well as the expertise of surgical-anesthesiologist team, can influence the feasibility of DCLC. Moreover a well-organized health community system is necessary to protect and follow the patients up. Our readmission and complication rates showed how a day case laparoscopic cholecystectomy, if performed in the right setting, is a safe procedure also for patient with a raised BMI. We enrolled a large population of patients and the statistical analysis demonstrated no significant differences among the obese and non-obese patient regarding the primary and secondary endpoints. CONCLUSIONS: DCLC is a safe and effective procedure in obese patients with morbidity, hospital admission and readmission rates similar to those observed in non-obese patients.

Emergency Hartmann's Procedure and Its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis.

BACKGROUND: Hartmann's procedure (HP) followed by reversal restoration is the first choice for treatment of diffuse diverticular peritonitis. There is no unanimous consensus regarding the use of laparoscopy to treat the same condition. METHODS: Data from 60 patients with diverticular diffuse peritonitis who underwent urgent HP followed by laparoscopic reversal were retrospectively analyzed. Patients were divided into 2 groups according to the open or laparoscopic HP (OHP, 24 patients; LHP, 36 patients). Outcomes were measured in terms of functional recovery, morbidity, mortality, and length of hospital stay. RESULTS: HPs showed no differences among the groups in terms of operative time, blood loss, and length of intensive care unit stay. Overall morbidity was significantly lower in LHP than in OHP, corresponding to 33.3% and 66.7% respectively ( P = .018). The incidence of both surgical and medical complications was higher in OHP than in LHP (41.7% vs 22.2% [ P = .044] and 45.8% vs 24.3% [ P = .023], respectively). Mortality was 16.6% for each group. LHP showed a faster return to bowel movements and a shorter hospital stay than OHP. The secondary intestinal reversal was possible in 92% of cases, successfully completed laparoscopically in 91.3%. No patients of LHP group required a conversion to open intestinal reversal. CONCLUSION: LHP for treatment of diverticular diffuse peritonitis showed significantly lower morbidity, faster recovery, shorter hospital stay, and higher rates of successful laparoscopic reversal when compared with OHP.

Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients.

Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m2) ≥30 were defined as obese, and patients with a BMI (kg/m2) <30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman group: A). In group A, the Laparoscopic Caiman 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman group than in the Historical group [104 vs 124 min (p 0.004), 116 vs 140 min (p 0.004), and 125 vs 151 min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman group than in the historical one [52 ml vs 93 for RC (p 0.003); 65 vs 120 ml for LC (p 0.001); 93 vs 145 ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.

Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-Ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device?

BACKGROUND: Percutaneous central venous port (CVP) placement using ultrasound-guidance (USG) via right internal jugular vein is described as a safe and effective procedure. The aim of this study is to determine whether intraoperative fluoroscopy (IF) and/or postoperative chest X-ray (CXR) are required to confirm the correct position of the catheter. METHODS: Between January 2012 and December 2014, 302 adult patients underwent elective CVP system placement under USG. The standard venous access site was the right internal jugular vein. The length of catheter was calculated based on the height of the patient. IF was always performed to confirm US findings. RESULTS: 176 patients were men and 126 were women and average height was 176.2 cm (range 154-193 cm). The average length of the catheter was 16.4 cm (range 14-18). Catheter malposition and pneumothorax were observed in 4 (1.3 %) and 3 (1 %) patients, respectively. IF confirmed the correct position of the catheter in all cases. Catheter misplacement (4 cases) was previously identified and corrected on USG. Our rates of pneumothorax are in accordance with those of the literature (0.5-3 %). CONCLUSION: Ultrasonography has resulted in improved safety and effectiveness of port system implantation. The routine use of CXR and IF should be considered unnecessary.

Extent of lymphadenectomy and perioperative therapies: two open issues in gastric cancer.

Gastric cancer is one of the leading causes of death for cancer worldwide, although geographical variations in incidence exist. Over the last decades, its incidence and mortality have gradually decreased in Western countries, while these have increased, or remained stable, in the other world regions. Gastric cancer is often diagnosed at an advanced stage, with the only notable exception of Japan, where nationwide screening programs are enforced, due to local high incidence. Curative- intent surgery (i.e., gastrectomy, total or partial, and lymphadenectomy) remains the cornerstone of treatment of gastric cancer. Much has been debated about the extent of lymph node dissection and, although it is a valuable contribution to staging and cure, operative treatment only represents one aspect of overall effective management, as the risk of both locoregional and distant recurrences are high, and bear a poor prognosis. As a matter of fact, surgery, as a single modality treatment, has probably achieved its maximum efficacy for local control and survival, while other accompanying nonsurgical treatment modalities have to be taken into account, although their role is still the subject of considerable debate. The authors in this review present an update on the outcome of treatment of gastric cancer in relation to the extent of lymphadenectomy and of various nonsurgical preoperative, intraoperative, and postoperative strategies.

Robotic hybrid technique in rectal surgery for deep pelvic endometriosis.

BACKGROUND: Deep pelvic endometriosis is a complex disorder that affects 6% to 12% of all women in childbearing age. The incidence of bowel endometriosis ranges between 5.3% and 12%, with rectum and sigma being the most frequently involved tracts, accounting for about 80% of cases. It has been reported that segmental colorectal resection is the best surgical option in terms of recurrence rate and improvement of symptoms. The aim of this study is to analyze indications, feasibility, limits, and short-term results of robotic (Da Vinci Surgical System)-assisted laparoscopic rectal sigmoidectomy for the treatment of deep pelvic endometriosis. PATIENTS AND METHODS: Between January 2006 and December 2010, 19 women with bowel endometriosis underwent colorectal resection through the robotic-assisted laparoscopic approach. Intraoperative and postoperative data were collected. All procedures were performed in a single center and short-term complications were evaluated. RESULTS: Nineteen robotic-assisted laparoscopic colorectal resections for infiltrating endometriosis were achieved. Additional procedures were performed in 7 patients (37%). No laparotomic conversion was performed. No intraoperative complications were observed. The mean operative time was 370 minutes (range = 250-720 minutes), and the estimated blood loss was 250 mL (range = 50-350 mL). The overall complication rate was 10% (2 rectovaginal fistulae). CONCLUSIONS: Deep pelvic endometriosis is a benign condition but may have substantial impact on quality of life due to severe pelvic symptoms. We believe that robotic-assisted laparoscopic colorectal resection is a feasible and relatively safe procedure in the context of close collaboration between gynecologists and surgeons for treatment of deep pelvic endometriosis with intestinal involvement, with low rates of complications and significant improvement of intestinal symptoms.

Elderly and very elderly patients with hepatocellular carcinoma. Strategy for a first line treatment.

AIM: Health-status of elderly patients with hepatocellular carcinoma (HCC) may limit surgical approach; other options are thus auspicable. METHODS: The authors reviewed 98 selected patients, aged 65 to 90 years, with 149 HCC treated between 2002 and 2011. According to the extent of malignancy, health status and treatment, patients were divided into 3 groups. Sixty-one, submitted to major and minor curative resections, were in group A and B while group C included 37 patients, unsuitable for high-risk procedures and percutaneous ablation, submitted to intraoperative-radiofrequency ablation (IRFA) alone or combined with minor resections. Assessment of safety and therapeutic efficacy of this managment was evaluated. RESULTS: A postoperative mortality rate of 1,02% and an overall survival rate at 5 years of 62.3% were observed. Indeeed matched post-operative morbidity and mortality rates of A, B, C groups were 45%, 8%, 16.21% (p < 0.004) and 9 %, 0%, 0% (p= 0.112 ) respectively. 3 years overall-survival was not statistically different (p= 0.585). However 5 years survival rate and disease-free-survival rate were significantly higher in patients of group A and B (p= 0.003; p< 0.001). CONCLUSION: Treatment strategies to minimize treatment-related morbidity and mortality have resulted satisfactory for early and late outcomes of an heterogeneous group of elderly patients with HCC.

Treatment of congenital liver cysts. A surgical technique tailored through a 35-year experience.

BACKGROUND: The most important aims of the treatment of CLC are long-term relief of symptoms and elimination of cysts. Treatment of choice is yet debated. METHODS: Data of patients treated for CLC during a 35-years experience were retrospectively analyzed. Variables analyzed were: age, sex, hepatic cyst location, cyst diameter, symptoms, surgical procedure, short and long-term outcomes. RESULTS: We examined 49 consecutive patients treated for CLC (mean follow-up, 76 months). The study was divided into two periods: 1975-1999 and 2000-2010. Procedures performed in the first period were needle aspiration and sclerotherapy (n= 6), hepatic resections (9), cystojejunostomy (4), open unroofing (10), and laparoscopic unroofing (8). Omentopexy within the residual cystic cavity was associated with seven open and two laparoscopic unroofing cases. Rates of morbidity and recurrence were 23.5% and 44.1%, respectively. One patient died in the peri-operative period. Procedures performed in the second period were open unroofing (9), laparoscopic unroofing (5), and hepatic resection (1). Omentopexy was associated with all open procedures and two laparoscopic procedures. Overall morbidity in this group was 16.6%, and recurrence occurred in one patient (6.7%). CONCLUSIONS: Cyst unroofing and omentopexy is a safe and highly effective procedure for the treatment of CLC. Laparoscopy is confirmed as the procedure of choice except for cases in which the cysts are in the posterior right liver, where a wide mobilization of the liver is necessary.

Desmoplastic fibroblastoma of the thigh. A case report.

Desmoplastic fibroblastoma (DF) is an extremely rare benign soft tissue tumor, prevalent in adult men, mostly arising in deep regions of extremities. The tumor presents with a slowly growing and no recurrence or metastases after surgical excision. Histologically, DF is characterized by a collagenous stroma that contains spindle- and stellated-shaped fibroblastic cells positive for vimentin. Differential diagnosis with locally aggressive soft tissue tumors could be difficult. This case report deals with the clinical pathological and immunoistochemical features of a DF of the left thigh in a 63-years old man.

Urgent surgery for sigmoid diverticulitis. Retrospective study of 118 patients.

OBJECTIVE: Aim of our study was to identij5 the risk factors for operative morbility and mortality after urgent surgery for complicated sigmoid diverticulitis. A further end point was define the adequate surgical approach in these patients. METHODS: Data fJom 118 patients who were admitted for emergency surgery between 2000 and 2009 for non-haemorrhagic complicated diverticulitis of the sigmoid colon were retrospectively evaluated and analysed. Operative options included resection with primary anastomoses (PA), Hartmann's procedure (HP) and colostomy. All operative complications were noted and potential risk factors listed. RESULTS: One hundred eighteen patients were enrolled in this study. Surgery for peritonitis was indicated for 102 patients and for intestinal obstruction in the remainder. Overall morbidity and mortality rates were 37.3% and 9.3%, respectively. Primary resection was performed on 113 patients (95.8%). Age greater than 70 years, diffuse peritonitis, Mannheim Peritonitis Index (MPI) above 18, and symptoms lasting longer than 24 hours are considered as independent risk factors for operative morbidity and mortality. DISCUSSION: Our results confirmed that while age older than 70 years and delaying treatment (>24h) are independent risk factors for operative morbidity and mortality, comorbidity is not. According to general guidelines, first target of surgery was to attempt a primary resection of the diseased colon (95.8% of our patients). In our series an high rate of Hartmann procedure (HP) in Hinchey's class 2 patients was observed. This unusually high number is explained by the rate (68.4%) of pelviperitonitis diagnosed in these patients. Extended pelvic peritonitis is generally defined as a local peritonitis (class 2 Hinchey), which is not accurate. Colonic resection in these cases would not completely remove peritoneal contamination and renders the indication for PA questionable. CONCLUSIONS: Emergency surgery for complicated diverticulitis is characterised by high rates of morbidity and mortality. Age greater than 70 years, symptoms lasting longer than 24 hours, MPI above 18, and diffuse peritonitis were significant predictors. Early eradication of septic focus is the main goal of surgery. Primary anastomosis is recommended only if sepsis is completely removed.

Anastomotic leakage and septic complications: impact on local recurrence in surgery of low rectal cancer.

PURPOSE: We thought to determine the influence of anastomotic leakages (AL) and septic complications (SC) on the incidence of local recurrence (LR) in patients undergoing curative surgery for rectal cancer. METHODS: The records of 479 patients (286 male, 193 female; median age 67 years) who received, between 1966 and 1975 (Group A) and 1976 and 1985 (Group B), curative surgery for middle to low rectal cancer were retrospectively reviewed. All patients received mesorectal excision in the course of abdominoperineal excision (Group A) and of anterior resection with colorectal anastomosis (Group B). The outcome of SC in both groups and that of AL in Group B were investigated. AL were divided into clinical leaks (CL) and radiological leaks (RL). All patients surviving surgery were followed up for a mean period of 71 months. The development of pelvic recurrence was registered. The effect of SC and AL on LR was statistically analyzed. RESULTS: LR was diagnosed in 24 (9.3%) patients of Group A. No difference was detected between patients with SC (9.3%) and those without (9.3%). In Group B, LR occurred in 28 (12.7%) patients: 12.5% without SC and 12.7% with SC. A significant difference in the prevalence of LR was found between patients with CL (14.2%) and those with RL (30.0%). When CL were excluded, RL resulted as an independent predictor of LR. DISCUSSION: Many factors have been shown to affect the rate of LR, including operative technique and surgeon expertise as well as margins of clearance and tumor stage. In our study, overall LR rate of Group B was 13.2%. The incidence of this event in patients with AL (24%) was significantly higher than that in the nonleakage group (11.1%). Correspondent results have been reported by some authors who evidenced RL as a negative prognostic factor for higher rates of LR. The mechanism by which AL affects LR remains to be elucidated. CONCLUSIONS: All were found to be associated with higher rates of LR, especially if associated with prolonged inflammatory local reaction.

Surgical treatment of hydatid disease of the liver: 25 years of experience.

BACKGROUND: The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease. METHODS: Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence. RESULTS: Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery. CONCLUSIONS: Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery.

Ghost ileostomy: real and potential advantages.

Loop ileostomy is created to minimize the clinical impact of colorectal anastomotic leak. However, a lot of complications may be associated with ileostomy presence and with its reversal. Moreover, patients hardly accept the quality of life resulting from ileostomy. We describe a simple technique (ghost ileostomy) to combine all the advantages of a disposable ileostomy without entailing its complications in patients submitted to low rectal resection. In case of uneventful postoperative course, the ghost ileostomy prevents all complications related to defunctioning ileostomy. At the same time, in case of anastomotic leakage, the ghost ileostomy is easily and safely converted into a defunctioning ileostomy.

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy.

BACKGROUND: Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES. METHODS: The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted. RESULTS: Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst. CONCLUSIONS: TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.