Laparoscopic posterior cruroplasty: a patient tailored approach.

BACKGROUND: Different surgical variations have been described for laparoscopic crural repair however, the technique is not standardized and left to the surgeons' preference. OBJECTIVE: The purpose of this study is to describe a standardized "patient tailored" approach for laparoscopic posterior cruroplasty in the setting of elective hiatal hernia repair. METHODS: Retrospective single-center study was conducted (November 2015 to November 2019). The technical aspects of a standardized "patient tailored" laparoscopic posterior crural repair are described. Perioperative outcomes and patients' quality of life, measured with the disease specific Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and generic Short Form-36 (SF-36), were analyzed. RESULTS: One hundred and forty-one patients were treated for symptomatic hiatal hernia according to the described "patient tailored" concept. Overall, 102 (72.3%) patients underwent simple suture repair while simple suture repair buttressed with biosynthetic resorbable U shaped mesh [Phasix ST®-Bard] was used in 39 (27.7%) patients. Toupet fundoplication was fashioned in all patients. The median operative time was 131 min (IQR 55-240). No intraoperative complications or conversion to open surgery occurred. The median postoperative stay was 1.8 days (range 1-7). The overall postoperative complication rate was 4.2%. The median follow-up was 21 months (IQR range 1-34) with 102 patients having a minimum follow-up of 6 months. Recurrent hernia was diagnosed in three patients (2.1%), but none required reoperation. No mesh-related complications occurred. Compared to baseline, the median GERD-HRQL (p = 0.003) and all SF-36 items (p < 0.001) were significantly improved. CONCLUSION: The application of a standardized "patient tailored" concept for laparoscopic posterior cruroplasty seems safe and effective in the medium-term follow-up with promising perioperative outcomes and quality of life improvement. This approach may be valuable to assure procedure reproducibility, standardization, and to uniformly interpret the outcomes.

Open mesh vs. suture umbilical hernia repair: systematic review and updated trial sequential meta-analysis of randomized controlled trials.

PURPOSE: To examine the updated evidence on safety, effectiveness, and outcomes of mesh versus suture elective umbilical hernia (UH) repair and to explore the timely tendency variations favouring one treatment over another. METHODS: MEDLINE and CENTRAL databases were consulted. A systematic review, pairwise meta-analysis, and trial sequential analysis (TSA) were conducted. RESULTS: Six RCTs were included for a total of 742 patients. Overall, 383 (51.6%) underwent mesh, while 359 (48.4%) underwent suture repair. The estimated pooled postoperative recurrence RR was 0.27 (95% CI 0.13-0.53; p < 0.001). The TSA showed a statistically significant timely tendency in favour of mesh repair with a boundary cross curve (Z = 1.96) before reaching the information size. The estimated pooled seroma, haematoma, and wound infection RR were 1.45 (p = 0.368), 0.54 (p = 0.196), and 0.71 (p = 0.375), respectively. The TSA for wound-related complications showed partial, non-significant results. CONCLUSIONS: Elective UH mesh repair seems to be associated with reduced risk of postoperative recurrence compared to simple suture repair with a statistically significant timely trend endorsed by the TSA. Definitive considerations concerning the cumulative effect for seroma, haematoma, and wound infection are premature. Further studies are warranted to endorse these results and deeply investigate the timely tendency variations.

Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis.

PURPOSE: To examine the current evidence on the therapeutic role and outcomes of robotic Transabdominal Preperitoneal Inguinal hernia repair (rTAPP) to better define its risk-benefit ratio and guide clinical decision-making. METHODS: PubMed, EMBASE, and Web of Science were consulted. A Frequentist single-arm study-level random effect meta-analysis was performed. RESULTS: Twelve studies published between 2015 and 2018 met the inclusion criteria (1645 patients). Patients' age ranged from 16 to 96, the BMI ranged from 19 to 35.6 kg/m2, and 86.1% were males. Unilateral hernia repair was performed in 69.6% while bilateral hernia repair was performed in 30.4% of patients. The operations were all conducted using the da Vinci Xi or Si robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). The rTAPP was successfully completed in 99.4% of patients and the operative time ranged from 45 to 180.4 min. The postoperative follow-up ranged from 16 to 368 days. The estimated pooled prevalence of intraoperative complications and conversion were 0.03% (95% CI 0.00-0.3) and 0.14% (95% CI 0.0-0.5%), respectively. The estimated pooled prevalence of urinary retention, seroma/hematoma, and overall complications were 3.5% (95% CI 1.6-5.8%), 4.1% (95% CI 1.6-7.5%), and 7.4% (95% CI 3.4-10.9%). The estimated pooled prevalence of hernia recurrence was 0.18% (95% CI 0.00-0.84%). CONCLUSIONS: Robotic technology has been progressively entering surgical thinking and gradually changing surgical procedures. Based on the results of the present study, the rTAPP seems feasible, safe, and effective in the short term for patients with unilateral and bilateral inguinal hernias. Further prospective studies and randomized controlled trials are needed to validate these findings.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair.

PURPOSE: The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. METHODS: PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. RESULTS: Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. CONCLUSIONS: This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Pharmacological approach to chronic visceral pain. Focus on oxycodone controlled release: an open multicentric study.

BACKGROUND AND OBJECTIVES: Visceral pain is a significant issue for patients, and the importance of treating pain is underestimated. New opioid formulations, the primary treatment option for moderate-to-severe pain, have been shown to be effective, but no studies have been conducted to address the efficacy of these agents for visceral pain. This study was conducted to determine the incidence of visceral pain in patients with uncontrolled moderate-to-severe pain, and to evaluate the efficacy of controlled-release (CR) oxycodone in this context. MATERIALS AND METHODS: s: In this multicenter, prospective, observational study, 967 of 980 evaluated patients were included, 350 (36.2%) of whom presented mainly visceral pain. In most cases (57.0%), patients had experienced pain for < or = 3 months, and the majority (94.9%) were cancer patients. Pain was uncontrolled in 340 (97.1%) patients, and was rated as severe in >2/3 of patients (mean numerical rating scale (NRS) value 7.04 +/- 1.68). Patients with uncontrolled pain were given oxycodone CR; all completed the 15-day study and no patient was switched to an alternative opioid. RESULTS: Oxycodone CR was associated with significant reductions in mean NRS value at day 3, 7 and 15 (final mean NRS 2.37 +/- 1.59) and the proportion of patients experiencing severe pain had decreased by the end of the study to 1.5%. The SF-12 questionnaire showed significant improvements in quality of life in all domains, and oxycodone CR was well tolerated. CONCLUSIONS: Oxycodone CR appears to be a very well tolerated and effective treatment for patients with visceral pain.

Use of oxycodone controlled-release immediately after NSAIDs: a new approach to obtain good pain control.

INTRODUCTION: Opioids are recommended as appropriate therapy for the treatment of cancer pain and chronic non-malignant pain. Oxycodone is an alternative agent to its parent compound, morphine, and is available in a controlled-release (CR) formulation that allows convenient twice-daily dosing. The aim of this study was to evaluate the efficacy and tolerability of oxycodone CR as first-line therapy in patients with chronic cancer or non-cancer pain that was not relieved by non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: This was a prospective, open-label, multicentre trial carried out in 8 pain and oncology centres in Italy. Patients (n = 309) with NSAID-refractory chronic cancer (55.7%), noncancer (39.4%) or mixed (4.9%) pain (rating of 4-10 on a numerical rating scale [NRS] from 0-10) were enrolled. Patients were treated with oral oxycodone CR twice daily for at least 28 days. Dosage was individualized for each patient and up-titrated over the first week of treatment. The primary endpoint was reduction in NRS score for pain. Secondary endpoints were tolerability, quality of life and patient assessment of treatment efficacy. RESULTS: A significant decrease (57%) in pain intensity was recorded during the first week of therapy (decrease in NRS score from 7.85 +/- 1.4 to 3.35 +/- 1.8; p < 0.00001). Overall, there was a 72.3% reduction in NRS pain score from baseline at the end of the study. Quality of life significantly (p < 0.005) improved during oxycodone therapy, and 91% of patients rated treatment as "effective" or "very effective". Five patients stopped oxycodone CR treatment because of adverse events, and one stopped treatment because of dysphagia. CONCLUSIONS: The results of this study demonstrate the efficacy and tolerability of oxycodone CR in patients with moderate-to-severe pain of a variety of aetiologies and confirm the feasibility and effectiveness of moving directly from step I to step III on the WHO analgesic treatment ladder.

Expression of long pentraxin PTX3 in human adipose tissue and its relation with cardiovascular risk factors.

UNLABELLED: Pentraxin 3 (PTX3) is an acute phase protein strongly expressed by advanced atherosclerotic lesions. We investigated (a) PTX3 expression and secretion in subcutaneous adipose tissue (SAT) and omental visceral adipose tissue (VAT) obtained from 21 obese (37.4+/-8.15 yr) and 10 normal weight subjects (43.7+/-11.07 yr) and (b) the relationships of adipose PTX3 with tumour necrosis factor alpha (TNFalpha) and adiponectin expression and with cardiometabolic risk factors. Real-time PCR was used to quantify specific mRNA for PTX3, CD68 (macrophage marker), TNFalpha and adiponectin. Fresh adipose tissue was cultured and PTX3 measured in the medium. Serum insulin, glucose, HDL and LDL cholesterol, triglycerides, C-reactive protein (CRP), fibrinogen, adiponectin, TNFalpha and PTX3 were measured. PTX3 expression was similar in the two fat compartments and tended to be higher in obese than in normal weight subjects in VAT only (p=0.05). CD68 and PTX3 expressions were correlated with each other in SAT but not in VAT. After adjustment for age and sex, VAT-PTX3 expression and release were correlated with VAT-TNFalpha expression (p<0.01 for both) and with LDL/HDL ratio (p<0.01 and p<0.001). VAT-PTX3 expression was also correlated with BMI, triglycerides, CRP, fibrinogen and adiponectin (p<0.05 for all). In the multivariate analysis with VAT-PTX3 RNA levels as dependent variable, LDL/HDL ratio and fibrinogen remained independently associated with VAT-PTX3 expression (p<0.01 for both). These associations were not seen within SAT. CONCLUSIONS: Human adipose tissue expresses and releases PTX3 likely under TNFalpha control. VAT production of PTX3 seems to contribute to the mechanisms underlying the development of atherosclerosis.

Type 2 diabetes and metabolic syndrome are associated with increased expression of 11beta-hydroxysteroid dehydrogenase 1 in obese subjects.

OBJECTIVE: The role of glucocorticoids production in adipose tissue in the development of metabolic disorders in humans has not been fully characterized. We investigated whether in obese subjects, 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) expression in subcutaneous (SAT) and visceral (VAT) adipose tissue is associated with the occurrence of metabolic disorders and the expression of adiponectin and tumor necrosis factor alpha (TNFalpha) and two glucocorticoid-regulated adipokines able to influence the metabolic control. DESIGN AND SUBJECTS: Sixty-two obese patients were enrolled in the study. SAT and VAT samples were obtained from 13 patients undergoing bariatric surgery (body mass index (BMI) 39.1+/-5.3 kg/m(2)). SAT samples were obtained from 49 patients who underwent periumbilical biopsy (BMI 36.9+/-5.1 kg/m(2)). MEASUREMENTS: Oral glucose tolerance tests in subjects without known diabetes. Circulating glucose, lipid, insulin, adiponectin, TNFalpha and urinary-free cortisol levels. Real-time PCR to quantify mRNA levels of 11beta-HSD1, hexose-6-phosphate dehydrogenase (H6PDH), adiponectin and TNFalpha. Western blot analysis to evaluate 11beta-HSD1 protein expression. RESULTS: In the majority of the obese subjects, VAT expresses more 11beta-HSD1 than SAT. VAT 11beta-HSD1 expression was not associated with metabolic disorders. SAT 11beta-HSD1 mRNA levels were higher in subjects with than in those without metabolic syndrome (P<0.05) and in patients with type 2 diabetes compared to patients with impaired or normal glucose tolerance (P<0.0001). SAT 11beta-HSD1 expression was independently related to fasting glucose (P<0.0001) and urinary-free cortisol levels (P<0.01), and increased expression of 11beta-HSD1 was associated with increased adiponectin and TNFalpha expression and decreased serum adiponectin levels (all P's <0.05). CONCLUSIONS: In obese subjects, increased 11beta-HSD1 expression in SAT, but not in VAT, is associated with the worsening of metabolic conditions. We hypothesize that higher glucocorticoid production in adipose tissue would favor the development of metabolic disorders through a decrease in adiponectin release.

Intragastric balloon: another option for treatment of obesity and morbid obesity.

BACKGROUND/AIMS: The BioEnterics Intragrastric Balloon (BIB, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity. METHODOLOGY: Since March 1998, 349 BIB were placed in 303 obese and morbidly obese patients; 95 patients were male and 208 female; mean age was 41.5 years (19-70); mean weight was 118.8 Kg (67-229); mean BMI was 42 Kg/m2, % excess weight was 62.3% (4.6-216.3). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 Kcal/day. RESULTS: After 4 months of balloon treatment, the mean weight loss was 13.9 Kg and the mean reduction in BMI was 4.8 Kg/m2. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. CONCLUSIONS: The best indications for BIB were: morbidly obese (BMI >40) and super-obese patients (BMI >50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbidity in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach.

Aspergillus vertebral osteomyelitis after simultaneous kidney-pancreas transplantation.

Aspergillus osteomyelitis is a rare complication of invasive aspergillosis after organ transplantation. This is the report of a 46-year-old man who underwent a simultaneous pancreas and kidney transplantation, complicated by an Aspergillus osteomyelitis and diskitis of the lumbar spine. Prompt diagnosis with needle biopsy, followed by antifungal therapy using caspofungin, a new antifungal agent recommended for the treatment of refractory aspergillosis, in combination with amphotericin B and an early surgical intervention led to clinical resolution of the infection. Reported cases of spinal aspergillosis after transplantation are reviewed in terms of clinical presentation, risk factors, therapeutic options, and outcome.

Treatment of morbid obesity with intragastric balloon in association with diet.

BACKGROUND: The BioEnterics Intragastric Balloon (BIB, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity. METHODS: Since March 1998, 322 BIB were placed in 281 obese and morbidly obese patients; 73 patients were male and 208 female; mean age was 41.6 years (21-70); mean weight was 117.4 kg (67-229); mean BMI was 41.8 kg/m2 (29-81); % excess weight was 62% (10-216). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 kcal/day. Also, for 18 months we compared 42 obese patients treated only with 1000 kcal/day diet (group A) with 31 obese patients subjected to BIB for 4 months + 1000 kcal/day diet (group B). RESULTS: After 4 months of balloon treatment, the mean weight loss was 13.9 kg and the mean reduction in BMI was 4.8. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. In the diet vs BIB + diet study, BIB with diet produced a greater weight loss in a shorter time than diet alone. CONCLUSION: The best indications for BIB were: morbidly obese opatients (BMI > 40) and super-obese patients (BMI > 50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI < 30 only in a multidisciplinary approach.

Adjustable gastric banding: 5-year experience.

BACKGROUND: From 1993 to 1999, 172 patients underwent adjustable silicone gastric banding (ASGB) or laparoscopic adjustable silicone gastric banding (LASGB). In 109 patients the adjustable band was placed via laparoscopy; in the other patients it was placed via laparotomy (prelaparoscopic era, conversions from other bariatric operations, conversions for laparoscopic failure). The conversion rate from laparoscopy to laparotomy was 9.3%, occurring in the early part of our experience. METHODS: Mean age was 37.9 years, weight 135 +/- 14.8 kg (82-218) and BMI 46.3 +/- 5.4 (35.1-69.5). All patients had multiple band adjustments, temporary antisecretive, electrolyte and vitamin therapy, and follow-up per routine. RESULTS: Weight loss at 3 years was 30.2%; mean percent loss of excess weight was 62.5%. There was no mortality. The most important technical complications were: gastric pouch dilatation that required band replacement or removal (5.8 %); mild gastric pouch dilatation reversible with adequate dietary and pharmacological treatment (4.6%); intraoperative gastric perforation (2.3%); band migration (0.6%). The band was removed in 2.3%, with conversion to another bariatric procedure in 1.1%. CONCLUSIONS: Results have been satisfactory thus far.

Intragastric balloon in obese patients.

BACKGROUND: Since March 1998, 143 BioEnterics Intragastric Balloons (BIB) were placed in 132 obese and morbidly obese patients, to study the clinical possibilities of a new system, both from the point of view of the materials used and the application method. METHODS: 36 patients were male and 96 female; mean age was 43 years (21-70); mean weight was 115.4 kg (67-229), and mean BMI was 41.0 (29-81). 8 patients were affected by severe respiratory insufficiency. We placed and removed the balloon endoscopically under conscious sedation or general anesthesia. BIB was removed in the majority of patients 4 months after insertion. The patients were given a balanced diet of 800-1000 kcal/day; follow-up involved a monthly check-up (routine blood tests, weight control) and a visit every 15 days with the dietitian. RESULTS: Mean weight loss was 14.4 kg; mean reduction in BMI was 5.2. Weight loss was much better in males. The weight loss produced an improvement of the complications associated with the obesity. Complications observed were: balloon intolerance (9 early removals), 1 balloon deflated and passed, 2 cases of gastric ulcer at balloon removal. CONCLUSIONS: The most correct indications for BIB should be: extremely obese patients (BMI>40) in preparation for a bariatric operation; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI<30 in a multidisciplinary approach.

[Video laparoscopic surgery and rectal prolapse. Our experience in rectopexy]. / Chirurgia videolaparoscopica e prolasso rettale. Nostra esperienza in tema di rettopessia.

BACKGROUND: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells. METHODS: Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography. RESULTS AND CONCLUSIONS: Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.

Intestinal Microflora Settlement in Patients with Jejunoileal Bypass for Morbid Obesity.

Intestinal microflora settlement was evaluated in this retrospective study of 49 patients with jejunoileal bypass who required reoperation. Colonic microflora was observed in the samples of the contents of the functioning jejunum and ileum but not in 55% of the samples from the middle of the excluded loop. Colonization of the excluded loop was not detected in patients without clinical signs of bacterial overgrowth but was significantly frequent (p < 0.01) in those with clinical signs (bloating, migratory arthralgias, rashes, skin lesions). However, positive excluded loop cultures were not always associated with clinical manifestations. No significant correlation was observed between bacteriology of the contents of the excluded loop and bypass results. The success of an intestinal bypass may depend not only on anatomic and functional adaptation to the new, surgically created conditions, but also to the attainment of microbiological equilibrium in the intestinal ecosystem.

[Percutaneous neurolysis of the celiac plexus. Description of a new CT-guided technique and preliminary results]. / Neurolisi percutanea del plesso celiaco. Descrizione di una nuova metodica TC-guidata e risultati preliminari.

June 1991 to June 1992, twelve CT-guided percutaneous celiac plexus neurolyses were performed by a new simplified technique with the patient in left-hand side decubitus and a single right lumbar needle access. CT guidance allows the interventional radiologist to locate the best access point on the skin, to give the needle the appropriate depth and inclination to avoid passing through pleura, parenchyma and vessels, and finally to check the correct position of the needle tip and the spread of neurolytic solution. In left-hand side decubitus, fat and loose connective tissue around ganglia and vessels expands much more, thus allowing the alcohol-contrast medium solution to spread easily and evenly getting to both celiac ganglia by gravity. The analgesic value of celiac plexus neurolysis has been proved complete and lasting. The technique is quick and safe (apart from inevitable hypotension due to splanchnic vasodilatation).