Single-Port Cholecystectomy for Cholecystitis Versus Non-Cholecystitis.

Background and Objectives: To assess the safety and efficacy of single-port laparoscopic cholecystectomy (SPLC) for the treatment of symptomatic cholelithiasis in different gallbladder pathologic conditions. Methods: All patients who underwent SPLC in our department between October 1, 2017 and March 31, 2020 were registered consecutively in a prospective database. Patients' charts were retrospectively divided according to histological diagnosis: normal gallbladder (NG) (n = 13), chronic cholecystitis (CC) (n =47), and acute cholecystitis (AC) (n = 10). The parameters for assessing the procedure outcome included operative time, blood loss, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and length of hospital stay. Patient groups were statistically compared. Results: Seventy patients underwent SPLC. Duration of surgery increased from NG (55 ± 22.7 min) to CC (70 ± 33.5 min), and to AC patients (110.5 ± 50.5 min), which is statistically significant (P = .001). Postoperative complication rates were 7.6% in NG patients, 17% in CC, and 30% in AC (P = .442). Length of hospitalization was shorter for NG patients (1.0 ± 0.6 days) versus CC (2.0 ± 1.1 days) and AC patients (2.0 ± 4.7 days), with statistical significance (P = .020). Multivariate analysis found that pathology type and the occurrence of postoperative complications were independent predictors for prolonged operative times and prolonged hospital stay, respectively. Conclusion: SPLC is feasible for acute and chronic cholecystitis with good procedural outcomes. Since SPLC technique itself can be sometimes challenging with the existing technology, its application, especially in cases of acute cholecystitis, should be done with caution. Only prospective randomized studies on this approach for acute and chronic gallbladder diseases will assess the complete reliability of this technique.

Fluorescence-guided laparoscopic lymph node biopsy in a lymphoma patient: a possible new clinical application of indocyanine green.

To date, there are no reports indicating the use of indocyanine green (ICG) fluorescence to detect pathologic lymphatic tissue when a laparoscopic lymph node biopsy (LLB) for suspected new or recurrent lymphoma is performed. We present the case of a 72-year-old female patient admitted for suspicion of recurrent lymphoma. A preoperative imaging work-up showed solid tissue enveloping the terminal portion of the abdominal aorta with a standardized uptake value (SUV) of 10. Therefore, an LLB was planned. After induction of anesthesia, a ICG solution was injected intravenously and subcutaneously at both inguinal regions. At laparoscopy, a complete visualization of the pathologic lymph nodes was achieved, enabling an incisional biopsy of the lymphomatous mass. LLB with ICG-fluorescence offers a simple and safe method for pathologic lymph node detection in the suspicion of intra-abdominal lymphoma. More studies with large case series are needed to confirm the efficacy of this application.

Therapeutic drug monitoring in Crohn's disease patients treated with anti-TNF: a comparison of two techniques.

BACKGROUND: Therapeutic drug monitoring is a useful clinical decision aid in managing patients with inflammatory bowel disease treated with anti-tumor necrosis factor (anti-TNF). Various techniques are available to evaluate drug trough levels, and among these a point-of-care (POC) method has been proposed to overcome the limitations inherent to other methodologies. In this study we aimed to evaluate the capability of POC to discriminate between relapse and remission disease phases, and to assess the concordance of the POC and homogeneous mobility shift assay (HMSA) results. METHODS: Drug trough level of 46 Crohn's disease patients treated with either adalimumab or infliximab were evaluated with both a POC technique and an HMSA at various time points (week-16 and -48) during anti-TNF treatment. RESULTS: Median adalimumab trough level of patients in remission were significantly higher as compared to relapsing patients using both HMSA (week 16, P = 0.0001; week48, P = 0.001) and POC (week 16, P = 0.0003; week 48, P = 0.0012), and similar results were observed with infliximab trough level at week 16 (HMSA, P = 0.019; POC, P = 0.0072). Overall, we observed a good correlation between the techniques for both infliximab (r = 0.76; P < 0.0001) and adalimumab (r = 0.75; P < 0.0001), with no difference in discriminatory accuracy between assays (infliximab: HMSA versus POC c-index, 0.921 versus 0.895, P =0.149; adalimumab: HMSA versus POC c-index, 0.817 versus 0.850, P = 0.197). CONCLUSION: Both POC and HMSA assays are able to reliably differentiate relapse and remission phases in Crohn's disease patients treated with anti-TNF. These techniques showed good concordance and we feel that their preferential use should be based on local accessibility, physicians' experience and preference, and the need for timeliness availability of results.

Single-Port vs. Conventional Multi-Port Laparoscopic Lymph Node Biopsy.

BACKGROUND AND OBJECTIVES: The purpose of the investigation was to compare clinical results and diagnostic accuracy for conventional multiport laparoscopic lymph node biopsy (MPLB) and single-port laparoscopic lymph node biopsy (SPLB) operations at a single institution. METHODS: A set of 20 SPLB patients operated on from October 2016 to May 2019 were compared to an historical series of 35 MPLB patients. Primary endpoints were the time of surgery, estimated blood loss, surgical conversion, length of stay and morbidity. The secondary endpoint was the diagnostic accuracy of the technique. RESULTS: SPLB was completed laparoscopically in all cases. Two MPLB patients (5.7%) experienced a surgical conversion due to intraoperative difficulties. Duration of surgery was similar in SPLB and MPLB groups respectively (84 ± 31.7 min vs. 81.1 ± 22.2; P = .455). A shorter duration of hospital stay was shown for patients operated on by SPLB compared to the MPLB group (1.7 ± 0.9 days vs. 2.1 ± 1.2 days; P = .133). The postoperative course was uneventful in both groups. In 95% of the SPLB and 97.1% of the MPLB cases respectively, LLB achieved the necessary information for the diagnosis. CONCLUSION: SPLB has shown good procedural and postoperative outcomes as well as a high diagnostic yield, comparable to traditional MPLB. Therefore, our results show that this approach is safe and effective and can be an equally valid option to MPLB to obtain a diagnosis or to follow the progression of a lymphoproliferative disease. Further studies are necessary to support these results before its widespread adoption.

SECCA procedure for anal incontinence and antibiotic treatment: a case report of anal abscess.

BACKGROUND: Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter. CASE PRESENTATION: We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years. CONCLUSIONS: The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess. We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.

A Case Report of Acute Diverticulitis in "Pseudodiverticulosis" after Hemorpex System® Procedure.

Introduction. In the last years many mini-invasive approaches were developed in order to reduce postoperative pain and complication after haemorrhoid surgery: one of these alternatives is represented by Hemorpex System, a relatively young technique that combines transanal dearterialization with mucopexy through a dedicated proctoscope. Case Presentation. A 78-year-old male patient was admitted to the Emergency Department for acute urinary retention and elevated temperature. Hemorpex procedure was performed 4 years before. Clinical, endoscopic, and radiological findings demonstrated the presence of multiple diverticula-like structures fulfilled by purulent fluid and a deep alteration of the normal anatomy of the rectum. He was treated following the standard protocol of acute diverticulitis and full recovery from symptoms was achieved. Discussion. Hemorpex System is a young technique, and nowadays-available studies lack long-term follow-up data. Anatomical changes induced by the procedure are consistent and definitive. Our patient luckily demonstrated a prompt response to conservative treatment, but it must be taken into account that, in case of medical treatment failure, surgical approach would be necessary and the actual patient anatomical changes could lead the surgeon to unavoidable threatening maneuvers.

Congenital internal hernia through defect in the falciform ligament in adult: A case report and review of the literature.

INTRODUCTION: The incidence of occlusion syndrome caused by internal hernia is very rare, in particular when the defect is congenital discovered in adults with no previous abdominal surgery. PRESENTATION OF CASE: We present a case of a 31 year-old female patient who presented with acute abdominal pain and mechanical obstruction. The patient had never undergone abdominal surgery. DISCUSSION: On diagnostic laparoscopy, it was found a herniation of a loop of small bowel through a hole in the falciform ligament. The obstruction was solved by the division of part of falciform ligament without intestinal resection. CONCLUSION: Internal hernia is a very uncommon pathology, most often discovered in pediatric age because of congenital abnormalities, it must be included in the differential diagnosis in adults. Preoperative diagnosis is difficult. The diagnostic laparoscopic approach has shown to be the best.

Splenectomy for E. coli abscess: A case report with a difficult preoperative diagnosis and unclear pathogenesis.

INTRODUCTION: Isolated splenic abscess is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is non-specific and the diagnosis is often delayed. Ultrasonography and CT scan are the gold standard. The treatment is still controversial: antibiotic therapy, percutaneous drainage (PCD) or splenectomy. CASE PRESENTATION: We present the clinical case of a patient, admitted to our Department because of abdominal pain, without fever. The preoperative radiological assesment showed three intrasplenic liquid collections, whose differential diagnosis was made between hematic collection and abscess. The treatment was splenectomy. The samples of collected liquid were positive for Escherichia Coli. CONCLUSION: In case of splenic abscess, splenectomy is the best therapeutic choice. The other therapeutical options like antibiotic therapy and PCD, can be used only in particular cases, but without the same efficacy.

Stapled Mesh Reinforcement Technique (SMART) to Prevent Parastomal Hernias: Our Initial Experience and Review of the Literature.

Parastomal hernia is one of the most common stoma related complication, with the correlated risk of incarceration, obstruction, and strangulation. The incidence is high (30-50%) and depends on the length of follow up. Different surgical options for repairing are defective with a 25-70% failure and recurrence rate. Prevention of parastomal hernia with mesh reinforcement seems to be effective. Three available trials are recruiting patients: Prism (with matrix porcine prothesis), Prevent (with preperitoneal polypropylene mesh), and the stapled polypropylene mesh stoma reinforcement technique (SMART). We performed the SMART procedure in six patients undergoing definitive colostomy. Our cases show that the procedure is rapid (duration range 15-20 minutes), cost effective (500 euro), and safe (in our experience, there are no post-surgical complications that are procedure-related). A long term follow-up and a higher number of patients will give us confirmation of the initial hopeful results.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results.

BACKGROUND: Re-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an "open" access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule. METHODS AND DESIGN: The LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively. DISCUSSION: The study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon's experience. TRIAL REGISTRATION: Current Controlled Trials ISRCTN93729016.

Tension-free primary closure with autologous platelet gel versus Vivostat- for the definitive treatment of chronic sacrococcygeal pilonidal disease.

OBJECTIVE: A randomized clinical trial was performed in patients with chronic or recurrent pilonidal sinus (PS) comparing primary closure coupled with random application of in house autologous platelet gel or produced by means of Vivostat- in order to assess whether a standardized product had an impact on the wound healing process. PATIENTS AND METHODS: Between June 2006 and June 2009, 100 patients (82 males, 18 females: median age 30 years; range, 16-51 years) underwent wide excision of the pilonidal area with midline tension-free closure and were randomly given either the in house autologous platelet gel (Group 1) or the Vivostat- gel (Group 2). RESULTS: Group 2 patients had shorter wound healing time (8 vs. 10 days; p<0.0001), time to return to full activity (11 vs. 16 days: p<0.0001), less uncomplicated fluid collections (120 vs. 190 ml: p<0.0001), and fewer postoperative wound complications (1/50=2% vs. 5/50=10%, p<0.001). After a median follow-up of 21 months (range: 4-40 months), two recurrences were detected in Group 1. CONCLUSION: The standardized production of platelet gel by means of the Vivostat- system guarantees the reproducibility of the procedure and its use was correlated with an improved outcome, with a high degree of patient satisfaction and better cosmetic results.

Regenerative medicine for the definitive surgical repair of pilonidal sinus. A new method of wound reconstruction.

OBJECTIVE: A retrospective analysis of patients undergoing surgery for complex (> or =3 tracks) or recurrent pilonidal sinus (PS) was performed; the results of this clinical experience were compared with an original method of primary wound closure, coupling a "tension-free" technique of wound reconstruction with autologous cryoplatelet gel application, in order to improve the wound healing process and reduce the postoperative disability period. PATIENTS AND METHODS: The retrospective analysis included 30 patients undergoing surgery for PS between January 2003 and May 2005: in the first group of 15 consecutive patients, the wound was left open to close secondarily while in the remaining 15 patients, primary closure by means of a "tension-free" technique of wound reconstruction was attempted. Between June 2005 and May 2006, another subset of 15 patients was prospectively recruited, coupling the "tension-free" technique of wound reconstruction with autologous cryoplatelet gel application. RESULTS: In the first group of patients, median postoperative disability accounted for 65 days with one recurrence. In the second group, primary healing was achieved in 11 patients, with a median postoperative disability of 28 days; two recurrences did occur. In the third group of patients, primary healing was achieved in all patients within 14 to 29 days, and no recurrence has yet been detected. CONCLUSION: Short follow-up notwithstanding, the simplicity of the operation, the use of autologous products and the minimal postoperative disability with complete wound healing suggest that this new approach may represent a useful alternative to current surgical techniques for PS excision.