The role of HIPEC in the treatment of peritoneal carcinomatosis from gastric cancer: between lights and shadows.

Gastric cancer is one of the most dreadful neoplastic diseases and remains the second cause of cancer death worldwide. Patients who develop peritoneal metastasis have a poor prognosis, with a median survival of less than 6 months. Despite being the cause of 60% of deaths from gastric cancer, peritoneal metastasis can still be considered a local disease and a local multidisciplinary approach can improve the prognosis even in this end-stage disease. At present, hyperthermic intraperitoneal chemotherapy (HIPEC) is the most widely accepted treatment for peritoneal surface diseases and can be performed in patients with different stages of cancer and with various antitumoral drugs. We performed a systematic review of the current status of HIPEC in the treatment of gastric peritoneal metastasis in an attempt to obtain answers to the questions that still remain: do results differ with these different methods? Does HIPEC exert a significant effect on the intracavitary delivery of drugs? Which patients should be treated and which should not? What can we expect from this approach in terms of survival, morbidity, and mortality? On reviewing the literature, despite the lack of trials comparing the different methods, we found that HIPEC has been shown to be an effective tool whenever a complete or an almost complete resection of the peritoneal implants can be performed. Therefore, it is advisable to refer all at-risk patients to specialized centers to be enrolled in randomized trials to achieve truly reliable results.

Pharmacokinetics of a new subcutaneous diclofenac formulation administered to three body sites: quadriceps, gluteus, and abdomen.

OBJECTIVE: To assess the relative bioavailability of a new subcutaneous (SC) diclofenac hydroxypropyl b-cyclodextrin (HPbCD) formulation administered to three body sites: quadriceps, gluteus, and abdomen. MATERIALS AND METHODS: This was a pilot, single-dose, randomized, three-way crossover relative bioavailability study. A total of 12 healthy subjects received a single SC injection of diclofenac HPbCD 50 mg/1 mL in the quadriceps, gluteus, or abdomen. RESULTS: The AUC was comparable after SC diclofenac HPbCD in the quadriceps, gluteus, and abdomen. The Cmax was comparable after SC administration in the quadriceps or abdomen, and ~ 17% higher in the gluteus. The absorption was rapid (30 minutes) after administration of the treatment at any site. The treatment was well tolerated. CONCLUSIONS: The relative bioavailability of SC diclofenac HPbCD was comparable when administered to the quadriceps, gluteus, and abdomen. The new diclofenac formulation can therefore be administered subcutaneously to any of these sites without clinically significant differences. A further adequately powered study would be necessary to reveal any differences among injection sites in terms of peak plasma concentration.

Giant gastrointestinal stromal tumor (GIST) of the stomach cause of high bowel obstruction: surgical management.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) represent 85% of all mesenchymal neoplasms that affect the gastrointestinal (GI) tract. These GISTs range in size from small lesions to large masses. Often they are clinically silent until they reach a significant size, so their discovery is usually incidental. CASE PRESENTATION: A 67-year-old man was admitted at our general surgery department with a persistent abdominal pain in the left hypochondrium, associated with nausea and vomiting. Clinical examination revealed a palpable mass in the epigastrium and in the left hypochondrium, which was approximately 40 cm long. Ultrasonography and computed tomography of the abdomen showed a large mass of 40 × 25 cm, which extended from the posterior wall of the stomach to the spleen, involving the body and the tail of the pancreas. The patient underwent en-block resection of the mass, sleeve resection of the stomach, and distal pancreatectomy-splenectomy. The histopathology of the resected specimen was consistent with a gastrointestinal stromal tumor of the stomach (positive for CD 117) with a high risk of malignancy (mitotic count >5/50 high-power fieldand Ki67/Mib1 >10%). The postoperative course was uneventful and treatment with imatinib mesylate began immediately. The patient appears to be disease free after four years. CONCLUSIONS: Giant GISTs of the stomach are rare. Surgical resection with curative intent is feasible. The combination of surgical resection and imatinib can provide long-termdisease-free survival. An R0 resection is the best achievable treatment, therefore the patient should be evaluated over time for potential resectability.

Human pharmacokinetics of the muscle relaxant, eperisone hydrochloride by liquid chromatography-electrospray tandem mass spectrometry.

Eperisone hydrochloride (4'-ethyl-2-methyl-3-piperidinopropiophenone hydrochloride) is a muscle relaxant agent, widely used in the treatment of patients with muscular contractures, low back pain or spasticity. Because of its mechanism of action (inhibition of gamma-efferent firing and local vasodilatation activity), side effects on central nervous system are rarely observed. A sensitive liquid chromatography-electrospray ionization-mass spectrometry method for determination of eperisone in human plasma has been developed, with a lower limit of quantification of 0.01 ng/mL. The method was applied to a pharmacokinetic study in 12 healthy volunteers given eperisone 100 mg as single dose on day 1 and three times daily on days 2 to 4. Eperisone was rapidly absorbed after oral administration (T (max) = 1.6 h) as it was expected by its fast-onset relaxant activity. Moreover, eperisone underwent a rapid elimination from the body (biological half-life 1.87 h), which was not modified during the repeated dosing as suggested by the C (max) cumulation observed, not different from that expected for a t (1/2) of 1.87 h as suggested by the similar and negligible plasma concentration values (0.063 and 0.067 ng/mL) measured on day 4 before the morning dose and 12 h after evening dose, thus ruling out any potential risk for drug accumulation. Thus, the pharmacokinetic characteristics of eperisone provide further justification for its tolerability in patients with low back pain or spastic palsy, in which the drug is given for periods ranging from few days to several months, respectively.

Is there a relationship between length of resection and lymph-node ratio in colorectal cancer?

BACKGROUND: The prognosis of colorectal cancer depends on the number of positive lymph nodes (LN+) and the total number of lymph nodes resected (rLN). This represents the lymph-node ratio (LNR). The aim of our study is to assess how the length of the resected specimen (RL) influences the prognostic values of the LNR. METHODS: We conducted a retrospective study of all the patients operated on for colorectal cancer from 2000 to 2015 at our institution. Pathology details were analysed. The total number of rLN, the number of LN+, and the LNR were calculated and measured against the RL. The receiver-operating characteristic (ROC) curve of patients with LN+ was calculated. RESULTS: Of the 670 patients included in our study, 337 were men (50.3%) and the mean age was 69.2 years. The correlation with prognosis of the LNR is greater than that of the LNR adjusted to RL (LNR/RL), both in subjects with positive nodes (n = 312) and in all cases (n = 670). The LNR presents a higher prognostic value than LNR/RL and RL in patients with LN+ except for metastatic recurrence, for which the predictive value appears slightly higher for LNR/RL. The statistical significance of the maximal divergence in Kaplan-Meier survival plots was demonstrated for the LNR (P = 0.043), not for LNR/RL (P = 0.373) and RL alone (P = 0.314). CONCLUSION: An increase in RL causes an increase in the number of harvested lymph nodes without affecting the number of LN+, thus representing a confounding factor that could alter the prognostic value of the LNR. Prospective larger-scale studies are needed to confirm these findings.

The surgical treatment of a rare complication: gallstone ileus.

The authors describe 3 cases of gallstone ileus observed in two different hospitals and evaluate the current rarity of this complication of the biliary lithiasis and/or of cholangiocarcinomas. There were two cases of stones at the ileal level and one case in the left colon. In one case a single surgical intervention was carried out while in the other a two-step strategy was adopted. Notwithstanding the fact that the correct strategy to adopt is still controversial in literature, the authors discuss the single and double step strategies and propose that the second intervention of the 2-step strategy should not be performed in high risk surgical patients.

The role of E-cadherin expression in the treatment of western undifferentiated early gastric cancer: Can a biological factor predict lymph node metastasis?

The use of endoscopic techniques to cure small sized, well differentiated early gastric cancer has been adopted worldwide. In the Eastern world, endoscopic resection is being increasingly utilized to treat small undifferentiated early gastric cancer according to the extended criteria proposed by the Japanese Gastric Cancer Associations. However, studies in the Western world reported in these tumors a rate of nodal metastasis ranging between 5% and 20%, that is higher of those observed in Eastern counterparts. A tool to predict the risk of nodal dissemination would be of great use to guide treatment toward endoscopic resection. In our study, we propose E-cadherin expression as a biological factor to predict lymph node involvement. We retrospectively reviewed the E-cadherin (E-cad) expression profile of all histological specimens of undifferentiated early gastric cancer from two Oncologic Departments and compared it with several tumor characteristics. A total of 39 patients with early gastric cancer met the inclusion criteria, of which 16 (41%) pT1a, and 23 (58.9%) pT1b SM1. Thirty-two patients (82%) underwent subtotal gastrectomy, whereas total gastrectomy was performed in only seven cases (17.9%). Patients were divided into two groups: low E-cad expression (E-cad 0/1+, 10 patients) and high E-cad expression (E-cad 2+/3+, 29 patients) according to the immunohistochemical assay (ICH). On univariate analysis, we found an association between low E-cad expression and low grading tumor (p = 0.019), pure undifferentiated histotype (PU-type) (p = 0.014), and lymph node involvement (N+) (p < 0.001). The association between low E-cad expression and lymph node metastasis was confirmed by multivariate analysis (OR = 14.5, 95% CI 3.46-60.76, p < 0.001). The loss of expression of E-cad may be a simple biological factor to predict lymph nodes metastasis in patients with undifferentiated early gastric cancer. Additional larger prospective studies are necessary to confirm these findings.

Acellular dermal matrix for breast reconstruction after surgery for giant dermatofibrosarcoma protuberans.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a rare neoplasm that exceptionally can affect the breast, always originating from skin and dermis, so imposing large sacrifice of skin. Only few cases have been reported of intraparenchymal DFS. We describe a unique case of giant intraparenchymal DFS that required removal of all the gland and reconstructive surgery. CASE REPORT: A 34 years old woman presents with a quickly growing breast mass, about 12 cm, with radiological features suggestive for giant fibroadenoma or mesenchymal neoplasm. The histology showed a Dermatofibrosarcoma protuberans infiltrating the surrounding parenchyma. The need for radicalization imposed, due to the size of the tumour, a nipple sparing mastectomy. The reconstruction has been performed using a new type of Acellular Dermal Matrix (ADM) mesh to wrap the prosthesis that has been placed and fixed over the great pectoral muscle. RESULTS: The final histologic report showed that the residual parenchyma and the skin removed were free from neoplastic infiltration. The patient is free from recurrence at 24 months from the surgery and the cosmetic result is excellent. DISCUSSION AND CONCLUSIONS: The treatment of DFSP should be aimed to prevent local recurrence, that are usually located in the scar or very close to it. Large size DFS can impose even mastectomy. If skin is not compromised like in this case, a nipple sparing mastectomy is suitable and the one time reconstruction with ADM wrapping of the prosthesis and fixation over the muscle can help to spare time, avoid complications and pain medication and reach excellent cosmetic resu. KEY WORDS: Acellular Dermal Matrix (ADM) mesh, Protuberans, Breast neoplasms, Dermatofibrosarcoma, Mastectomy, Nipple sparing, reconstructive surgery.

Laparoscopic repair of incisional hernia. Risk factors for the conversion.

INTRODUCTION: Some factors may affect the conversion to open of the laparoscopic treatment of incisional hernia. Their presence can help to choose the most appropriate technique identifying patients at high risk conversion. METHODS: A retrospective study has been performed on a cohort of 306 patients, selected among those undergone to elective laparoscopic surgery for post incisional hernia between 2005 and 2015. Only symptomatic patients with single site wall defect, diameter between 5 and 10 cm, ASA ≤3, have been included. Patients were divided in 2 groups, Laparoscopic (L) and Converted (C) and preoperatory data were evaluated and statistically analyzed. RESULTS: The L group accounted for 228 patients and C group for 78 patients. The univariate analysis showed that risk factor for conversion included BMI ≥ 30, Smoking, Diabetes mellitus, Prior emergency surgery. Age > 60 years was associate with lower risk of conversion. CONCLUSIONS: The result of this retrospective study allows us to say that the choice of the technique, in the presence of multiple risk factors, should be carefully assessed and discussed with the patient. A prospective study with a larger number of patients would allow a better definition of the risk determined by individual factors and the development of a score that could be used in practice to simplify the risk assessment KEY WORDS: Conversion to open surgery, Incisional hernia, Laparoscopy, Risk factors.

Superficial parotidectomy as first choice for parotid tumours.

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

[Incisional hernia at the trocar site in laparoscopic surgery]. / Il laparocele su "trocar site" in chirurgia laparoscopica.

The main aim of this study was to evaluate the incidence of incisional hernia at the trocar site, as well as to contribute towards defining the etiopathogenetic factors responsible. One hundred and fifty cases of patients undergoing laparoscopic surgery were studied retrospectively from the clinical and ultrasonographical points of view. The laparoscopic gaps examined numbered approximately 600 in all. The incidence of incisional hernia was 2%, exclusively located in the periumbilical area. There were no incisional hernias in extra-umbilical areas, which we usually do not suture. A symptomatic extra-umbilical incisional hernia occurred at a 5 mm site in a patient previously operated on in another hospital. Particular attention needs to be paid to periumbilical gap suture, exposed to the trauma of trocar fixing, especially in obese and diabetic patients. In selected cases the other gaps should be sutured, including the 5 mm ones.

Immunological reaction and oxidative stress after light or heavy polypropylene mesh implantation in inguinal hernioplasty: A CONSORT-prospective, randomized, clinical trial.

UNLABELLED: The relationship between mesh weight and host tissue reaction has, so far, not been fully investigated. Lightweight meshes (LWM) are thought to give less inflammatory response compared with heavyweight meshes (HWM). The present study is a randomized, controlled, double-blind clinical trial performed in 61 patients who underwent an elective inguinal hernioplasty. The primary outcome of the study was to investigate the relationship between total amount of prosthetic material (polypropylene), immunological reaction, and oxidative stress. The study was double-blinded. Sixty-one patients were recruited for the study and randomly assigned to 2 groups (groups A and B). Levels of inflammation markers (interleukin-6 [IL-6] and tumor necrosis factor-α [TNF-α]) and oxidative stress markers (reduced glutathione [GSH] and lipid hydroperoxides [LOOH]) were determined preoperatively and after undergoing inguinal hernioplasty (after 6, 72, and 288 hours), respectively, with LWM and HWM. There was no significant difference in IL-6 levels between HWM and LWM (P = 0.3, 0.7, 0.8 after 6, 72, and 288 hours, respectively). A statistically significant difference was found after 72 hours for TNF-α (P = 0.01), for GSH after 6 hours (P < 0.01), and after 6 and 72 hours for LOOH (P = 0.05, 0.01, respectively). Oxidative stress occurred at earlier time points and was pore accentuated HWM versus LWM and prodromal to TNF-α increase.Also, in randomized clinical trial, the use of LWM gives advantages in terms of less inflammatory response when compared with HWM. Moreover, there is a significant higher oxidative stress after implantation of HWM. The intensity of oxidative stress seems to be strongly related to the amount of implanted polypropylene. ( TRIAL REGISTRATION NUMBER: NCT01090284).

[Varicocele and coincidental abacterial prostato-vesiculitis: negative role about the sperm output]. / Varicocele and coincidental abacterial prostato-vesiculitis: negative role about the sperm output.

OBJECTIVE: To evaluate the frequency and the role of a coincidentally expressed abacterial prostato-vesiculitis (PV) on sperm output in patients with left varicocele (Vr). MATERIALS AND METHODS: We evaluated 143 selected infertile patients (mean age 27 years, range 21-43), with oligo- and/or astheno- and/or teratozoospermia (OAT) subdivided in two groups. Group A included 76 patients with previous varicocelectomy and persistent OAT. Group B included 67 infertile patients (mean age 26 years, range 21-37) with OAT and not varicocelectomized. Patients with Vr and coincidental didymo-epididymal ultrasound (US) abnormalities were excluded from the study. Following rectal prostato-vesicular ultrasonography, each group was subdivided in two subsets on the basis of the absence (group A: subset Vr-/PV-; and group B: subset Vr+/PV-) or the presence of an abacterial PV (group A: subset Vr-/PV+; group B: subset Vr+/PV+). Particularly, PV was present in 47.4% and 41.8% patients of groups A and B, respectively. This coincidental pathology was ipsilateral with Vr in the 61% of the cases. Semen analysis was performed in all patients. RESULTS: Patients of group A showed a total sperm number significantly higher than those found in group B. In presence of PV, sperm parameters were not significantly different between matched--subsets (Vr-/PV+ vs. Vr+/PV+). In absence of PV, the sperm density, the total sperm number and the percentage of forward motility from subset with previous varicocelectomy (Vr-/PV) exhibited values significantly higher than those found in the matched--subset (Vr+/PV-). CONCLUSION: Sperm analysis alone performed in patients with left Vr is not a useful prognostic post-varicocelectomy marker. Since following varicocelectomy a lack of sperm response could mask another coincidental pathology, the identification through US scans of a possible PV may be mandatory. On the other hand, an integrated uro-andrological approach, including US scans, allows to enucleate subsets of patients with Vr alone, who will have an expected better sperm response following Vr repair.

[Antibiotic prophylaxis in laparotomic and laparoscopic cholecystectomy]. / La profilassi antibiotica nella colecistectomia laparoscopica e laparotomica.

Antibiotic prophylaxis in biliary surgery, when correctly used, has led to the minimisation of postoperative infections. Conventional cholecystectomy, and particularly laparoscopic cholecystectomy give rise to a very complicated issue concerning the use of antimicrobial prophylaxis, especially in relation to low-risk patients. The authors describe their experience with the use of short-term prophylaxis in biliary surgery based on a hundred consecutive laparoscopic cholecystectomies. In addition, the literature on this topic strengthens the authors' conviction that antimicrobial prophylaxis may be indicated in all surgical cholecystectomy procedures, also in view of the difficult management of postoperative infection risk factors.

[Polypoid lesions of the gallbladder: indications for surgical treatment]. / Le lesioni polipoidi della colecisti: indicazioni all'intervento chirurgico.

Through the study of a population of 176 patients with polypoid lesions of the gallbladder, our aim was to demonstrate the advantages of ultrasonography in the identification of those cases in which surgical intervention is indicated. From among our patients, specific criteria were used to select 92 patients to submit to cholecystectomy. These criteria were based on a thorough evaluation of the clinical data (patient's age, familiarity, presence of symptoms), and on careful examination of the ultrasonographic images (number and size of lesions, presence of associated cholelithiasis, state of the gallbladder wall). The histological results and the literature data confirmed the validity of our protocol. The risk factors for carcinoma are age (> 60 years), coexistence of gallstone disease, and the size of the lesions (> 10 mm). Therefore, when these risk factors are present, cholecystectomy is justified even in asymptomatic patients.

[Biologic tolerance of prolene prosthesis in inguinal hernia repair]. / Tolleranza biologica della protesi in prolene nella riparazione dell'ernia inguinale.

The aim of this study was to evaluate the efficacy, safety and durability of a calibrated inguinal hernioplasty polypropylene prosthesis, particularly in relation to the microbiological phenomena that may set in the vicinity of the polypropylene plugs and mesh employed. Over the period from January 1994 to December 2002, 1416 operations were carried out for inguinal hernia. In 5 of these patients we conducted an immunological study to assess serum cytokine concentrations. In addition, we incubated peripheral blood mononuclear cells for 24 or 72 hours in RPMI 1640 medium added with 10% FCS, with or without 0.5 cm2 of polypropylene. We then evaluated cytokine levels in the supernatant of these cultures. It proved impossible, either in vivo or in vitro, to detect appreciable levels of IL-10 or IP-10. Serum levels of IFN-gamma, TNF-alpha, IL-18 and IL-6 increased in the postoperative phases as compared to the preoperative period. In the study performed in vitro, in the presence of prosthetic material there was a remarkable increase in the production of TNF-alpha and INF-gamma both in basal conditions and after an appropriate mitogenic stimulus. The results of this study allow us to speculate that the use of polypropylene induces remarkable chemotactic activity in the tissues adjacent to the prosthesis. The in-vitro study data suggest that the presence of polypropylene may stimulate the immunocompetent cells of patients with prosthetic implants.

Presentation and management of splenic injury after colonoscopy: a systematic review.

This study reviewed all single experience of splenic injuries after colonoscopy in the last 40 years to define the possible risk factors and the management of this complication. A MEDLINE and a PubMed search was undertaken to identify articles in English, French, Spanish, and Italian from 1974 to 2012 using the key words: "splenic injury," "splenic rupture," and "colonoscopy." Data were analyzed using descriptive statistic. A total of 103 cases have been described in 75 reports. The majority of the patients were women (71.56%) and 6.85% underwent previous pelvic surgery. The mean age was 63 years (range, 29 to 90 y). About 61 of the 103 studies (59.2%) reported the presence or the absence of previous abdominal surgery and within these, only 31 of 61 patients (50.82%) underwent previous abdominal surgery. In this review, over half of the patients with splenic injury underwent colonoscopy for routine surveillance (62.75%), and only one third of the splenic injures were associated with biopsy or polypectomy. The majority of patients (78.57%) developed symptoms within the first 24 hours after colonoscopy and in a minority of cases (21.43%), there was a delayed presentation 24 hours after colonoscopy. Computed tomography was used as the primary modality to make the diagnosis in 69 of 98 cases (70.41%) and as a confirmatory test in many additional cases. Twenty-six of 102 patients (25.49%) were treated by conservative methods, whereas the majority of patients (69.61%) underwent splenectomy as a definitive treatment. Because of possible medicolegal implications, the endoscopists should consider mentioning splenic injury on the consent form of colonoscopy after bowel perforation and bleeding, particularly in higher risk patients.

The role of 68-Ga-DOTATOC CT-PET in surgical tactic for gastric neuroendocrine tumors treatment: our experience: a case report.

Gastric neuroendocrine tumors (g-NETs), which originate from gastric enterochromaffin-like (ECL) mucosal cells and account for 2.4% of all carcinoids, are increasingly recognized due to expanding indications of upper gastrointestinal endoscopy. Often silent and benign, g-NETs may however, be aggressive and sometimes they mimic the course of gastric adenocarcinoma. Current nosography distinguishes those occurring in chronic conditions with hypergastrinemia, as the type 1 associated with chronic atrophic gastritis, and the type 2 associated with Zollinger-Ellison syndrome in MEN1. Conversely, type 3 and 4 (according to some authors) are unrelated to hypergastrinemia and are frequently malignant, with a propension to develop distant metastases. While there is a general agreement concerning the treatment of malignant gastric neuroendocrine tumors, for types 1 and 2, current possibilities include surveillance, endoscopic polypectomy, surgical excision, associated or not with surgical antrectomy, or total gastrectomy. This report, based on our clinical experience, discusses how the size, number, depth, histological grading, staging with CT, MRI, and the use of recently developed somatostatin receptor tracers (68Ga-DOTATATE, 68Ga-DOTA-TOC) could allow the correct identification of a benign or malignant propensity of an individual tumor, thus avoiding underestimation or overtreatment of these uncommon neoplasms.

The safety of the Harmonic® FOCUS in open thyroidectomy: a prospective, randomized study comparing the Harmonic® FOCUS and traditional suture ligation (knot and tie) technique.

Since Kocher and Billroth refined an acceptable technique, the thyroidectomy has become one of the most frequent procedures in endocrine surgery and bilateral total thyroidectomy is performed in the majority of thyroid diseases. This work evaluated the use of the Harmonic(®) FOCUS and traditional suture ligation (knot and tie) technique in a prospective, randomized study of open thyroidectomy. Eighty two patients were randomized and divided into two similarly sized groups: the Harmonic(®) FOCUS group (F group) and traditional group (T group). The use of the harmonic FOCUS shows some statistically significant advantages limited to a few intraoperative parameters: surgical time and volume of blood loss. The surgical time was significantly shorter in F group than in the T group (105 ± 27 min vs 143 ± 32 respectively; p < 0.05). Intraoperative volume blood loss was significantly more in the T group than in the F group (36 ± 23 ml vs. 24 ± 18; p < 0.05). The postoperative parameters (volume of drainage fluid, serum calcium at 12 and 48 h, hypocalcemia, wound complication, RLN palsy, postoperative pain and length of hospital stay) showed no statistical difference. The Harmonic Focus may provide a cost-effective option only in high volume centers where reducing operative time may balance the number of daily procedures.

Staple line as a cause of unusual early internal hernia after appendectomy.

The use of mechanical stapling devices in laparoscopic appendectomies has become a common practice. Occasionally, the retained staples have been described to cause adhesions that might result in bowel obstruction. Early bowel obstruction after routine abdominal surgery should be closely investigated and might warrant early re-exploration. We present a rare case of small bowel obstruction caused by a staple line adhesive band one week after appendectomy. A 46-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. A linear endoscopic stapling device was utilized during the procedure. The patient was discharged without complication. One week later, the patient presented to the emergency room for abdominal pain and she was discharged after adequate pain control. Several hours later she returned with similar symptoms, and she was diagnosed with distal small bowel obstruction by computed tomography scan. During the diagnostic laparoscopy there was an internal hernia through a defect created by the appendiceal staple line and the adjacent small bowel mesentery. After reduction of the hernia, the small bowel venous drainage improved, and no intestinal resection was necessary. The offending staple was removed and the staple line covered with omentum. The patient had complete resolution of symptoms and she was discharged the following day. No perioperative complications occurred. Mechanical staplers are routinely used in laparoscopic appendectomy. The staple line should be inspected at the end of the procedure to confirm the absence of free, unformed staples that can generate adhesions and postoperative complications.