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BACKGROUND: Obesity is a risk factor for ventral hernia development and affects up to 60% of patients undergoing ventral hernia repair. It is also associated with a higher rate of surgical site occurrences and an increased risk of recurrence after ventral hernia repair, but data is lacking on the differences between obesity classes. METHODS: Between 2008 and 2018, 322 patients with obesity underwent laparoscopic ventral hernia repair in our department: class I n = 231 (72%), II n = 55 (17%), III n = 36 (11%). We compared short and long-term outcomes between the three classes. RESULTS: Patients with class III obesity had a longer median length of hospital stay compared to I and II (5 days versus 4 days in the other groups, p = 0.0006), but without differences in postoperative complications or surgical site occurrences. After a median follow up of 49 months, there were no significant differences in the incidence of seroma, recurrence, chronic pain, pseudorecurrence and port-site hernia. At multivariate analysis, risk factors for recurrence were presence of a lateral defect and previous hernia repair; risk factors for seroma were immunosuppression, defect > 15 cm and more than one previous hernia repair; the only risk factor for postoperative complications was chronic obstructive pulmonary disease. CONCLUSION: Class III obesity is associated with longer length of hospital stay after laparoscopic ventral hernia repair, but without differences in postoperative complications and long-term outcomes compared with class I and class II obesity.
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Hérnia Ventral , Laparoscopia , Índice de Massa Corporal , Hérnia Ventral/complicações , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Obesidade/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Recidiva , Estudos Retrospectivos , Telas CirúrgicasRESUMO
The presence of hepatic vascular anomalies may add challenges to an already difficult surgery such as pancreatoduodenectomy, particularly when performed laparoscopically. Thus, our aim was to assess the impact of an aberrant right hepatic artery (aRHA) on postoperative outcomes during laparoscopic pancreatoduodenectomy (LPD) . Data of patients who underwent LPD were prospectively gathered and retrospectively analyzed. Patients with types III, IV, VI, VII, VIII, and IX anomalies according to Michels' classification were included in the aRHA group and were compared with the remaining patients (nRHA group). 72 patients underwent LPD; 14 of these had an aRHA (19.4%). Except for BMI (p = 0.021), the two groups did not differ in terms of clinico-pathological characteristics. The two groups had similar postoperative complications (p = 0.123), pancreatic fistula (p = 0.790), biliary leakage (p = 0.209), postpancreatectomy hemorrhage (p = 0.790), reoperations (p = 0.416), and mortality (p = 0.312). The median number of lymph nodes harvested was higher in aRHA group (p = 0.032), while R0 resection rate was similar between groups (p = 0.635). At the multivariate analysis, only moderate/high FRS (OR 3.95, p = 0.039) was an independent predictor of postoperative complications. This study suggests that aRHA has no negative impact on surgical and oncological outcomes in patients undergoing LPD.
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Laparoscopia , Neoplasias Pancreáticas , Humanos , Laparoscopia/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
Despite recent advances in minimally invasive pancreatic surgery, laparoscopic pancreaticoduodenectomy (LPD) has not reach a wide diffusion, mainly due to its technical difficulty. Considering its potential benefits, efforts should be made to improve its adoption. Between January 2017 and March 2020, LPD was offered as the primary approach to all the patients with an indication to pancreaticoduodenectomy. The overall cohort was divided into two groups: the early group (EG), including the first 30 cases, and the late group (LG), with the remaining patients. Perioperative data were gathered from a prospectively collected database and retrospectively analyzed, comparing the short-term outcomes of the two groups. In the study period, 52 patients underwent LPD. Among these, 88.4% patients were preoperatively diagnosed with a malignant disease. No difference was found between EG and LG in terms of baseline characteristics, mean operative time, estimated blood loss, and conversion to laparotomy. The overall complication rate was 57.7%, with severe complications occurring in 14 patients (26.9%). Two patients (3.8%) deceased within 90 days from the operation. No difference was found between EG and LG regarding postoperative outcomes. Among oncological patients, 86.7% received an R0 resection, and 13.3% had an R1 resection. The EG and LG did not differ in terms of oncological radicality and number of lymph nodes retrieved. LPD is a reproducible surgical technique that may provide acceptable results in both early and late phase of experience, when performed by surgical team with broad background in laparoscopic surgery.
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PURPOSE: Prophylactic mesh placement has been proposed to reduce the high occurrence of parastomal hernia (PSH) after stoma formation. METHODS: This is an observational study comparing two cohorts of patients: a mesh prophylaxis group (who received mesh prevention since introduction at our Institution) and a no mesh prophylaxis group (retrospectively selected from our historical series). Same exclusion criteria were applied for both groups. The study was conducted at a tertiary referral center for colorectal surgery. 43 patients were operated with mesh prophylaxis between May 2015 and may 2019. 45 patients underwent end-colostomy formation without prophylaxis between April 2011 and April 2015. The primary outcome measure was PSH development at 12-month follow up. RESULTS: Demographic variables and risk factors for PSH were comparable between the two groups. There was no difference between the two cohorts in terms of operative time and main early postoperative outcomes. 37 patients completed the 12-month follow up in each group. PSH occurrence after 12-months was 11% in the mesh prophylaxis group and 54% in the no mesh prophylaxis group (p < 0.0001). There were no differences in long-term complications. 5% of patients who received mesh prophylaxis underwent emergency surgery for bowel occlusion at 7 and 10 months after surgery, with partial or complete mesh removal. At multivariate analysis, mesh prophylaxis was a protective factor for PSH development at 12 months (p < 0.0001). CONCLUSIONS: Prophylactic intraperitoneal mesh placement appears to be effective in preventing PSH.
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Hérnia Ventral , Estomas Cirúrgicos , Colostomia , Hérnia Ventral/prevenção & controle , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Telas Cirúrgicas , Estomas Cirúrgicos/efeitos adversosRESUMO
INTRODUCTION: Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). METHODS: In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes. RESULTS: Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups. CONCLUSION: Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.
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Tratamentos com Preservação do Órgão/métodos , Pancreatectomia/métodos , Fístula Pancreática/diagnóstico , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/diagnóstico , Esplenectomia/métodos , Adulto , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/efeitos adversos , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/complicações , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Esplenectomia/efeitos adversosRESUMO
INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a demanding operation that has not yet gained popularity. Safety, feasibility, and clinical advantages of LPD in comparison with open pancreaticoduodenectomy (OPD) have not been clearly demonstrated. The aim of this study was to compare the short term outcomes of LPD with those of OPD. MATERIAL AND METHODS: Data from a prospectively collected database of patients who underwent pancreaticoduodenectomy at our institution between January 2013 and March 2020 were retrieved and analyzed, comparing the short-term postoperative outcomes of LPD and OPD, using a propensity score matching analysis. RESULTS: In the study period, 177 patients undergoing pancreaticoduodenectomy were selected, 52 of these were LPD. In the LPD group, the conversion rate to OPD was 3.8%. After matching, a total of 50 LPD and 50 OPD were compared. LPD was associated with a shorter length of stay (14 vs 20 days, p = 0.011), decreased blood loss (255 vs 350 ml, p = 0.022), but longer median operative time (590 vs 382.5 min; p < 0.001). No significant difference was found between LPD and OPD in terms of overall complications (56% vs 62%, p = 0.542), severe complications (26% vs 22%, p = 0.640), and postoperative mortality (4% vs 6%, p = 0.646). The groups had similar reoperation rate, pancreatic-specific complications, and readmission rate. CONCLUSIONS: In comparison with the open approach, LPD seems associated to with improved short-term outcomes in terms of hospital stay and blood loss, but with a longer operative time. No difference in morbidity and mortality rate were found in our series.
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Adenocarcinoma/cirurgia , Ampola Hepatopancreática , Neoplasias do Ducto Colédoco/cirurgia , Tempo de Internação/estatística & dados numéricos , Tumores Neuroendócrinos/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Idoso , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Cistadenoma Seroso/cirurgia , Feminino , Humanos , Análise de Intenção de Tratamento , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Mortalidade , Neoplasias Intraductais Pancreáticas/cirurgia , Pancreatite Crônica/cirurgia , Pontuação de PropensãoRESUMO
Introduction: Laparoscopic pancreaticoduodendectomy is still rarely adopted due to its inherent complexity. We hereby present our experience of laparoscopic pancreaticoduodenectomy focused on technical notes. Technical description: A 5 trocars technique is used. Vision is provided by a 30 degree scope with 4K technology for the demolitive phase and 3D for the reconstructive phase. The right colic flexure is mobilized and an extensive Kocher maneuver is carried out exposing the inferior vena cava and left renal vein. The gastric antrum is resected with a mechanical stapler. The common hepatic artery is identified behind the superior pancreatic margin; lymphadenectomy of stations 7, 8, 9, 12 a and b is performed, until the gastroduodenal artery is cleared from the lymphatic tissue; a bull-dog clamp is placed to interrupt the arterial flow through the gastroduodenal artery, in order to exclude aberrant vascularization of the liver from the SMA. The common hepatic duct is transected just above the cystic duct. The pancreas is sectioned with monopolar energy, dividing the main pancreatic duct 2-3 mm distal to the parenchymal transection line with cold scissors, as to leave a stump that will facilitate the duct-to-mucosa anastomosis then the first jejunal loop is sectioned. A complete dissection of the mesopancreas is performed, moving from a caudal to cephalad fashion. Prior to perform the pancreatico-jejunal anastomosis, a fistula risk score based on pancreatic parenchymal texture, tumor type, Wirsung diameter, intraoperative blood loss is assessed. The pancreatico-jejunal anastomosis is carried out using prolene and pds sutures. The end-to-side hepaticojejunostomy is performed about 10 cm distant from the pancreaticojejunostomy. The side to- side gastrojejunostomy is performed using a 60 mm linear stapler. Conclusion: Laparoscopic pancreaticoduodenectomy is a demanding procedure affected by high morbidity rates. The standardization of the technique could lead the way to reduce such rates and favor its adoption.
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Laparoscopia , Pancreaticoduodenectomia , Anastomose Cirúrgica , Humanos , Neoplasias Pancreáticas , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: The efficacy and safety of glecaprevir/pibrentasvir (G/P) for patients infected with hepatitis C virus (HCV) have only been investigated in clinical trials, with no real-world data currently available. The aim of our study was to investigate the effectiveness and safety of G/P in a real-world setting. METHODS: All patients with HCV consecutively starting G/P between October 2017 and January 2018 within the NAVIGATORE-Lombardia Network were analyzed. G/P was administered according to drug label (8, 12 or 16â¯weeks). Fibrosis was staged either histologically or by liver stiffness measurement. Sustained virological response (SVR) was defined as undetectable HCV-RNA 12â¯weeks after the end of treatment. RESULTS: A total of 723 patients (50% males) were treated with G/P, 89% for 8â¯weeks. The median age of our cohort was 58â¯years, with a median body mass index of 23.9â¯kg/m2, and median liver stiffness measurement of 6.1â¯kPa; 84% were F0-2 and 16% were interferon-experienced. Median HCV-RNA was 1,102,600â¯IU/ml, and 49% of patients had HCV genotype 1 (32% 1b), 28% genotype 2, 10% genotype 3 and 13% genotype 4. The median estimated glomerular filtration rate was 90.2â¯ml/min, platelet count 209x103/mm3 and albumin 4.3â¯g/dl. The SVR rates were 94% in intention-to-treat and 99.3% in per protocol analysis (8-week vs. 12 or 16-week: 99.2% vs. 100%). Five patients failed therapy because of post-treatment relapse; a post-treatment NS5A resistance-associated substitution was detected in 1 case. SVR rates were lower in males (p = 0.002) and in HCV genotype-3 (p = 0.046) patients treated for 8â¯weeks, but independent of treatment duration, fibrosis stage, baseline HCV-RNA, HIV co-infection, chronic kidney disease stage and viral kinetics. Mild adverse events were reported in 8.3% of the patients, and 0.7% of them prematurely withdrew treatment. Three patients died of drug-unrelated causes. CONCLUSIONS: In a large real-world cohort of Italian patients, we confirmed the excellent effectiveness and safety of G/P administered for 8, 12 or 16â¯weeks. LAY SUMMARY: A large number of patients with hepatitis C virus have been treated with glecaprevir/pibrentasvir (G/P) within the NAVIGATORE-Lombardia Network, in Italy. This is the first real-world study evaluating effectiveness and safety of G/P in patients with hepatitis C virus treated according to international recommendations. This study demonstrated excellent effectiveness (with sustained virological response rates of 99.3%) and safety profiles.
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Benzimidazóis , Hepatite C Crônica , Fígado/patologia , Quinoxalinas , Sulfonamidas , Ácidos Aminoisobutíricos , Antivirais/administração & dosagem , Antivirais/efeitos adversos , Benzimidazóis/administração & dosagem , Benzimidazóis/efeitos adversos , Biópsia/métodos , Estudos de Coortes , Ciclopropanos , Combinação de Medicamentos , Técnicas de Imagem por Elasticidade/métodos , Feminino , Hepacivirus/efeitos dos fármacos , Hepacivirus/genética , Hepatite C Crônica/complicações , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/epidemiologia , Humanos , Itália/epidemiologia , Lactamas Macrocíclicas , Leucina/análogos & derivados , Cirrose Hepática/diagnóstico , Cirrose Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Prolina/análogos & derivados , Pirrolidinas , Quinoxalinas/administração & dosagem , Quinoxalinas/efeitos adversos , RNA Viral/análise , Sulfonamidas/administração & dosagem , Sulfonamidas/efeitos adversos , Resposta Viral Sustentada , Resultado do TratamentoRESUMO
The stromal vascular cell fraction (SVF) of visceral and subcutaneous adipose tissue (VAT and SAT) has increasingly come into focus in stem cell research, since these compartments represent a rich source of multipotent adipose-derived stem cells (ASCs). ASCs exhibit a self-renewal potential and differentiation capacity. Our aim was to study the different expression of the embryonic stem cell markers NANOG (homeobox protein NANOG), SOX2 (SRY (sex determining region Y)-box 2) and OCT4 (octamer-binding transcription factor 4) and to evaluate if there exists a hierarchal role in this network in ASCs derived from both SAT and VAT. ASCs were isolated from SAT and VAT biopsies of 72 consenting patients (23 men, 47 women; age 45 ± 10; BMI between 25 ± 5 and 30 ± 5 range) undergoing elective open-abdominal surgery. Sphere-forming capability was evaluated by plating cells in low adhesion plastic. Stem cell markers CD90, CD105, CD29, CD31, CD45 and CD146 were analyzed by flow cytometry, and the stem cell transcription factors NANOG, SOX2 and OCT4 were detected by immunoblotting and real-time PCR. NANOG, SOX2 and OCT4 interplay was explored by gene silencing. ASCs from VAT and SAT confirmed their mesenchymal stem cell (MSC) phenotype expressing the specific MSC markers CD90, CD105, NANOG, SOX2 and OCT4. NANOG silencing induced a significant OCT4 (70 ± 0.05%) and SOX2 (75 ± 0.03%) downregulation, whereas SOX2 silencing did not affect NANOG gene expression. Adipose tissue is an important source of MSC, and siRNA experiments endorse a hierarchical role of NANOG in the complex transcription network that regulates pluripotency.
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Tecido Adiposo/citologia , Proteína Homeobox Nanog/metabolismo , Adulto , Diferenciação Celular/genética , Diferenciação Celular/fisiologia , Células-Tronco Embrionárias/citologia , Células-Tronco Embrionárias/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proteína Homeobox Nanog/genética , Fator 3 de Transcrição de Octâmero/genética , Fator 3 de Transcrição de Octâmero/metabolismo , Reação em Cadeia da Polimerase em Tempo Real , Fatores de Transcrição SOXB1/genética , Fatores de Transcrição SOXB1/metabolismoRESUMO
UNLABELLED: represents a safe and complete technique to remove benign lesions of the rectum not treatable by endoscopy and malignant rectal lesions at early stage. It is a valid alternative to transanal endoscopic microsurgery (TEM), to conventional transanal surgery and to transabdominal resection. METHODS: In our operating Unit we performed a resection of 8 voluminous adenoma in the rectal ampulla with SILSTM-Port. RESULTS: The mean age of the patients was of 51.1 years, the mean BMI was 23. There were not intra or post-operative complications nor conversions to conventional transanal excision or major resective surgery. The postoperative course was normal. The average time of hospitalization was 3 days. CONCLUSIONS: TEVA is easier to perform than TEM and does not require a long training and specific and expensive material as the TEM does. TEVA might go to replace completely TEM. KEY WORDS: Rectal tumours, SILS, TEVA.
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Adenoma/cirurgia , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/métodos , Cirurgia Vídeoassistida/métodos , Adenoma Viloso/cirurgia , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Itália , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND/AIMS: The best treatment for chronic hepatitis C patients who do not respond to interferon is still unknown. Reported rates of response to treatment vary as the result of heterogeneous definitions of non-responders and small study size. METHODS: One hundred nineteen hepatitis C virus (HCV) RNA-positive non-responders to high-dose interferon monotherapy received alpha-interferon, 5 MU tiw plus oral ribavirin, 1000-1200 mg/day for 48 weeks (Group A, n=74) or alpha-interferon, 5 MU daily for 4 weeks, followed by 5 MU tiw plus oral ribavirin, 1000-1200 mg/day for 44 weeks (Group B, n=45) according to the Institution where they were followed. Persistently normal alanine aminotransferase and negative HCV RNA up to 72 weeks from treatment onset defined a sustained response. RESULTS: Eighteen patients discontinued treatment (13 developed anemia, two mucositis, one granulocytopenia; two were dropouts), none for serious adverse events. There were 24 (20%) sustained responders, with similar final response rates in Groups A and B. Sustained response was more frequent in patients aged =40 years (36% vs. 13%; P=0.006) and in those with non-1 genotype (44% vs. 14%; P=0.002). Among genotype 1 patients, the younger ones showed higher response rates (32% vs. 7%; P=0.005). Compared with patients harboring non-1 genotypes, the odds ratio of being a non-responder was 1.68 (confidence interval (CI): 0.53-5.37; P=0.381) in younger genotype 1 patients and 9.53 (CI: 2.84-32; P<0.001) in older genotype 1 patients. CONCLUSIONS: Chronic hepatitis C patients who are non-responders to interferon monotherapy and infected by non-1 genotypes should undergo re-treatment with combination therapy. Treatment should be extended to younger genotype 1 patients who are more susceptible to liver disease worsening because of longer life expectancy and have a higher probability of being long lasting responders than their older counterparts.
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Antivirais/administração & dosagem , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/administração & dosagem , Ribavirina/administração & dosagem , Adulto , Idoso , Antivirais/efeitos adversos , Farmacorresistência Viral , Quimioterapia Combinada , Feminino , Genótipo , Hepacivirus/genética , Humanos , Interferon-alfa/efeitos adversos , Masculino , Pessoa de Meia-Idade , Ribavirina/efeitos adversosRESUMO
OBJECTIVES: It has been suggested that iron depletion improves the response to interferon in patients with chronic hepatitis C. We aimed to evaluate whether iron reduction by phlebotomy before interferon improves the rate of virological sustained response in previously untreated noncirrhotic patients. METHODS: One hundred fourteen hepatitis C virus (HCV) RNA positive patients with hepatic iron concentrations of > or =700 microg/g dry wt (men) and > or =500 microg/g dry wt (women), stratified according to HCV genotype and gamma-glutamyltransferase values, were randomly allocated to interferon alone (6 MU three times a week) (group A) or to phlebotomy until iron depletion followed by interferon (6 MU three times a week) (group B). After 4 months dosage was reduced to 3 MU three times a week for another 8 months. RESULTS: Virological sustained response was observed in 25 patients (22%), nine (15.8%, 95% CI = 7.5-27.9) of group A and 16 (28.1%, 95% CI = 17.0-41.6) of group B. At univariate analysis the variables associated with the response were HCV genotypes 2-3, normal gamma-glutamyltransferase, higher levels of baseline ALT, normal ALT values, and negativity for HCV-RNA at the 3rd month of therapy. At multivariate analysis, genotype and ALT levels at enrollment maintained their association with the response. A trend toward a better response to interferon was observed in patients who received phlebotomy (odds ratio = 2.32, 95% CI = 0.96-6.24, p = 0.082). Patients with hepatic iron concentration of < or = 1100 microg/g dry wt had a trend toward a higher rate of virological sustained response (p = 0.059) when submitted to treatment B. CONCLUSION: Iron removal by phlebotomy is able to improve the rate of response to interferon, especially in patients with lower hepatic iron deposits; it could be useful as adjuvant therapy to new therapeutic modalities.