Traumatic limb wounds management: Efficacy of silver and hyaluronic acid-containing dressings.

Traumatic limb wound management represents a common and challenging health problem. Conservative treatment can be a good option when surgery fails or surgical reconstruction is planned. Wound healing is a complex process that involves several factors and can be delayed if wound details are not noticed. So, expert healthcare professionals should take care of these delicate patients to obtain satisfactory outcomes in terms of cosmesis and functionality of the residual scar. Thanks to the description of three patients with traumatic limb injuries, this article emphasizes the importance of respecting what we call the three golden rules of wound management: correct cleaning of the wound, its accurate inspection and choose the appropriate dressing according to the wound aspect.

Near-infrared fluorescent cholangiography - real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.

BACKGROUND: The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy. METHODS: Fifty consecutive elective laparoscopic cholecystectomies were performed with fluorescent cholangiography. FC was performed at three time points: following exposure of Calot's triangle, prior to any dissection; and after partial and complete dissection of Calot's triangle. RESULTS: The cystic duct (CD) was identified successfully by FC in 43 of 50 patients (86%) and in 45 of 50 patients (90%) before and after Calot's dissection respectively (p > 0.05). The common hepatic duct (CHD) and the common bile duct (CBD) were identified successfully in 12 of 50 patients (24%) and in 33 of 50 patients (66%) before Calot's dissection respectively and in 26 of 50 patients (52%) and in 47 of 50 patients (94%) after complete Calot's dissection (p = 0.007 and p = 0.001, respectively). Significant differences were observed for CBD visualization rate, in relation to BMI after Calot's dissection (p < 0.05) and history of cholecystitis, before Calot's dissection (p = 0.017). No bile duct injuries were reported. CONCLUSION: Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies.

Ileocolonic anastomosis: preferred techniques in 999 patients. A multicentric study.

PURPOSE: There is no standard anastomosis technique for performing reconstruction after right hemicolectomy, and, in the literature, studies on ileocolonic anastomosis are rare. The aim of this retrospective work was to analyze the type of anastomosis techniques used and the related results in a multicentric enquiry. METHODS: A questionnaire was sent to the departments of surgery covering a 1.8 million inhabitant area to collect data concerning the anastomosis techniques used and the results related to complications. RESULTS: Data for 999 patients from 14 departments of surgery were collected. 95.8% of the patients were affected by cancer and 4.2% were affected by inflammatory bowel disease (IBD). The positioning of the anastomosing bowel was side-to-side in 60.5% of the patients, end-to-side (E-S) in 38.1% of the patients and end-to-end in 1.3% of the patients. 46.4% of the anastomoses were handsewn and 53.6% were stapled. The complication rate in the cancer group was 5.1% for handsewn techniques and 4.7% for stapled techniques. The rate of anastomotic leakage was higher in the handsewn group than that in the stapled group (P < 0.05). The data for the IBD group were not statistically relevant. CONCLUSIONS: This wide multicentric retrospective analysis showed that there remains variability in ileocolonic anastomosis techniques. Stapled anastomoses are associated with a lower incidence of leakage. In stapled anastomoses, the E-S configuration is also related to a lower incidence of leakage.

Hemopatch® is effective and safe to use: real-world data from a prospective European registry study.

Surgical procedures are often impeded by bleeding and/or leakage of body fluids. These complications cannot always be resolved by conventional surgical techniques. Hemopatch® is a hemostatic patch that also functions as a sealant. Here we document the effectiveness and safety of Hemopatch® for routine procedures of multiple surgical disciplines. To this end, we performed a prospective, multicenter, single-arm, observational registry study. Patients were eligible if they had received Hemopatch® during an open or minimally invasive procedure in one of these specialties: hepatobiliary, cardiovascular, urological, neurological/spinal, general, or lung surgery. Patients were excluded if they had a known hypersensitivity to bovine proteins or brilliant blue, intraoperative pulsatile or severe bleeding and/or infection at the target application site (TAS). The primary endpoint for intraoperative effectiveness was hemostasis assessed as the percentage of patients achieving hemostasis within 2 min and the percentage of patients achieving hemostasis without re-bleeding at the time of surgical closure. The registry enrolled 621 patients at 23 study sites in six European countries. Six hundred twenty patients had completed follow-up information. Hemostasis within 2 min was achieved at 463 (74.5%) of all 621 TASs. Hemostasis without re-bleeding was observed at 620 (99.8%) TASs. Adverse events were reported in 64 patients (10.3%). This Hemopatch® registry shows that Hemopatch® efficiently establishes hemostasis and sealing in a variety of surgical specialties, including minimally invasive procedures. Furthermore, we provide evidence for the safety of Hemopatch® across all the specialties included in the registry. This study is registered at clinicaltrials.gov: NCT03392662.

Recurrent aortoduodenal fistula.

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Quantifying the scientific interest in surgical training and education: numerical evidence of a PubMed analysis.

The scientific interest (SI) for a given field can be ascertained by quantifying the volume of published research. We quantified the SI in surgical education to clarify the extent of worldwide efforts on this crucial factor required to improve health-care systems. A set of Medical Subject Headings (MeSH) was defined for the PubMed search. The number of Pubmed Indexed Papers (nPIP) relevant to the SI was extracted from database conception to December 2016 and their distribution and evolution by country were analyzed at 10-year intervals. Population Adjusted Index (PAI) and Medical School Adjusted Index (MSAI) analyses were performed for countries with the nPIP > 30. We identified 51,713 articles written in 33 different languages related to surgical education; 87.6% of these were written in English. General surgery was the leading surgical specialty. The overall nPIP doubled every 10 years from 1987 (from 6009 to 13,501, to 26,272) but stabilized at 3707, 3800 and 3433 in the past 3 years, respectively. The PAI and MSAI analyses showed that the USA, United Kingdom, New Zealand, Canada, Australia and Ireland are top producers of published research in surgical education, constituting a combined 62.88% of the nPIP. Our quantification of the change in SI in surgical education and training gives a clear picture of evolution, efforts and leadership worldwide over time. This picture mirrors an international academic society that should encourage all those involved in surgical education to improve efforts in educational research.

Traumatic perforated diverticulum of the fourth duodenal portion: First case report and literature review.

INTRODUCTION: Duodenal rupture following blunt abdominal trauma is rare, and traumatic rupture of duodenal diverticula is exceptional. However, duodenum is the second most frequent location of intestinal diverticula following colon. Duodenal diverticula are common but only in few cases they are symptomatic due to the onset of complications such as inflammation, hemorrhage, or perforation. Perforation, although rare, especially post-trauma, is the most serious life threatening complication. CASE PRESENTATION: We report the case of a patient who, 24 hours after a blunt trauma secondary to a car accident, complained symptoms related to the perforation of a diverticulum of the fourth portion of the duodenum. A computed tomography was performed and extraluminal fluid-air collection was identified. During emergent laparotomy, a fourth portion perforated duodenal diverticulum was diagnosed, and resected. The recovery was uneventful. DISCUSSION: Diagnosis of perforated duodenal diverticulum represents a challenge in diagnosis and few guidelines exist about the management of this rare occurrence, especially in a traumatic setting. The present case is the first report of traumatic perforated diverticulum of the fourth duodenal portion. CONCLUSION: Surgery still remain the most common approach in the treatment of this pathology, including diverticulectomy and primary repair.

Is the sublay self-gripping mesh effective for incisional ventral hernia repair? Our experience and a systematic review of the literature.

Sublay mesh repair seems to be the most effective method for treating incisional hernias (IHs). The aim of this study was to report our experience with retromuscular repair and self-gripping mesh for the treatment of midline IHs. In addition, we provided a systematic review of the literature regarding the use of this novel combination. All patients undergoing elective IH repair from June 2016 to November 2018 were included. The self-gripping mesh was placed in the sublay position. Demographic data, defect sizes, postoperative complications and follow-up durations were collected. A systematic review of the available literature was conducted in January 2020 using main databases. A total of 37 patients (20/17M/F) were included in this study, and the mean age and body mass index (BMI) were 58 years and 27 kg/m2, respectively. Minor complications occurred in six patients. Long-term follow-up demonstrated recurrence in three patients. Regarding the review, five publications were considered relevant. The highest complication rate was 28.6%, and the recurrence rate varied from 0 to 5.1%. This is the first review of the literature regarding sublay IH repair using a self-gripping mesh. The low rates of postoperative complications and recurrence in our experience and those reported by most of the reviewed articles demonstrate that this is a safe and effective method for repairing IHs.

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

Biological Mesh Combined With Topical Negative Pressure Therapy in Complex Abdominal Wounds: A Short Series and a Review of the Literature.

INTRODUCTION: Complex abdominal wounds (CAWs) are an increasing clinical problem in abdominal surgery and pose a challenge for the surgeon. OBJECTIVE: This review analyzes the results of treating CAWs with a porcine biological mesh and topical negative pressure (TNP) to address the feasibility, effectiveness, level of risk, and overall results. MATERIALS AND METHODS: A series of 4 consecutive cases treated with the biologic mesh and TNP at the General Surgery Unit of the Cannizzaro Hospital (Catania, Italy) is reported and analyzed. In addition, a review of the literature published in all languages from 2000 to 2015 in the MEDLINE/PubMed database was performed to identify cases of CAWs treated with the association of biologic mesh and TNP. RESULTS: Taking into account the authors' experience and review of literature, a total of 12 patients (4 treated in the authors' department) were treated with the aforementioned combination. The main indications for using this association were a large abdominal wall defect, laparotomy, or wound dehiscence and wound infection. In almost all cases, this combination demonstrated a successful outcome with a clear improvement in wound healing and no adverse effects. CONCLUSIONS: From these cases and the review of the literature, the authors believe TNP can be applied on a biological mesh with effectiveness in improving the treatment of the CAWs without relevant risk to the patient or biological mesh.

A retrospective, Italian multicenter study of complex abdominal wall defect repair with a Permacol biological mesh.

Complex abdominal wall defects (CAWDs) can be difficult to repair and using a conventional synthetic mesh is often unsuitable. A biological mesh might offer a solution for CAWD repair, but the clinical outcomes are unclear. Here, we evaluated the efficacy of a cross-linked, acellular porcine dermal collagen matrix implant (Permacol) for CAWD repair in a cohort of 60 patients. Here, 58.3% patients presented with a grade 3 hernia (according to the Ventral Hernia Working Group grading system) and a contaminated surgical field. Permacol was implanted as a bridge in 46.7%, as an underlay (intraperitoneal position) in 38.3% and as a sublay (retromuscolar position) in 15% of patients. Fascia closure was achieved in 53.3% of patients. The surgical site occurrence rate was 35% and the defect size significantly influenced the probability of post-operative complications. The long-term (2 year) hernia recurrence rate was 36.2%. This study represents the first large multi-centre Italian case series on Permacol implants in patients with a CAWD. Our data suggest that Permacol is a feasible strategy to repair a CAWD, with acceptable early complications and long-term (2 year) recurrence rates.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis.

BACKGROUND: Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV). METHODS: A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options. RESULTS: Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems. CONCLUSIONS: There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Laparo-endoscopic "Rendezvous" to treat cholecysto-choledocolithiasis: Effective, safe and simplifies the endoscopist's work.

AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized "tailored" RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire. RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone's recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases. CONCLUSION: Simultaneous RV carries high effectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.

[Perineo-ano-rectal injuries: clinical experience]. / I traunmi perineo-ano-rettali: esperienza clinica.

Traumatic lesions involving the rectum, perineum and anus are infrequent but difficult to treat, requiring experience with trauma and colo-proctological surgery. The aim of the treatment is to repair the lesions and to minimise the early complications which are the main cause of failure and of late complications and disability. The most complicated lesions present problems concerning either the surgical strategy or the surgical timing, both of which are essential for a successful outcome. The Authors analyse their recent clinical experience with 7 patients with complex traumatic lesions involving the rectum, perineum and anus, excluding those of gynaecological/obstetric origin and those not involving the sphincter. They evaluated the clinical history, causes and types of lesions, as well as treatment, complications and outcomes. Five of the lesions were caused by impalement, one by an explosion and one by a motorboat propeller blade. Six of the patients (85.7%) were treated by direct primary repair and one (14.3%) by secondary repair after a previous colostomy. All 7 patients achieved complete recovery of the lesions. Only two cases (28.6%) of early complications and one case (14.3%) of persistent minimal sphincter dysfunction occurred. On the basis of these good results, the clinical experience and the literature, the Authors suggest that these perineo-ano-rectal lesions, though often complex, may often be cured by early surgery, confining colostomy only to particular cases. In addition to experience with trauma and the timing of colo-proctological surgery, a knowledge of all the available surgical options is mandatory to achieve the best results.

Laparoscopic resection of a large GIST of the stomach: is it preferable in elderly patients? A case report.

Gastrointestinal stromal tumour (GIST) of the stomach is extremely rare in the elderly. Surgical resection of the stomach by partial gastrectomy or wedge resection is the standard treatment. Today the resection can also be performed laparoscopically, especially in the case of small tumours as well as for larger GIST though there are unclearly defined oncological limits. The authors report the successful treatment of a large 7.5 cm GIST of the stomach by laparoscopic wedge resection in a 78-year-old patient. The GIST was almost entirely located intraperitoneally between the stomach and the spleen and could be radically resected with a minimal touch technique. The patient recovered promptly and manifested no recurrence at a 2-year follow-up. The authors focus on the main factors supporting the indication for laparoscopic resection of large gastric GIST, especially in the elderly. The surgical risk/benefit ratios of the different approaches, the surgeon's skills in laparoscopically respecting the rules of oncological surgery, and informed consent of the patient in relation to the limited scientific evidence concerning the main risk factors of recurrence are all important considerations.

Dystopic retrohepatic gallbladder and cholecysto-choledocho lithiasis: the rendez-vous and indocyanine green fluorescence.

Laparoscopic cholecystectomy is a well-known procedure for the treatment of most gallbladder diseases. Sometimes, it could be very difficult, in the presence of aberrations regarding the cystic duct, the cystic artery, or the gallbladder itself. Fluorescence laparoscopy using indocyanine green could be very useful for all the situations of anatomy aberrations.

Rendezvous technique versus endoscopic retrograde cholangiopancreatography to treat bile duct stones reduces endoscopic time and pancreatic damage.

BACKGROUND: Endoscopic procedures on Vater's papilla are related to pancreatic damage with or without pathologic increase of pancreatic enzymes. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is a standard treatment for common bile duct stones, performed sequentially before or after laparoscopic cholecystectomy. The "rendezvous" (RV) procedure combines laparoscopic cholecystectomy, intra-operative cholangiography, and endoscopic bile duct clearance and is an alternative to the sequential treatment. We tried to analyze relevant differences between the two options concerning the main parameters of pancreatic damage. METHODS: Thirty-eight patients treated for biliary stones were divided into two groups of 19 patients depending on the type of treatment (RV vs. ERCP) and were compared for post-procedural amylase and lipase levels; the duration of the endoscopic procedures, effectiveness, and complications were also recorded. RESULTS: A pathologic increase of serum amylase occurred in 15.7% of the RV group and 47.3% of the ERCP group with significant differences regarding amylase levels in the 6- and 66-hour samples (p < 0.003; p < 0.006). The mean duration of endoscopic procedure was significantly shorter in the RV group (17 vs. 26 minutes, p < 0.0001). RV was effective in common bile duct clearance in 100% of cases, while ERCP was effective in only 89.5%. Minor morbidity affected one patient in each group. CONCLUSIONS: This is the first report comparing combined laparoendoscopic RV versus ERCP for potential pancreatic damage and showing that RV reduces the number of patients with an iatrogenic pathologic increase of amylase when compared to ERCP, and also significantly reduces the duration of endoscopic procedure.

Efficacy of the Laparoendoscopic "Rendezvous" to Treat Cholecystocholedocholithiasis in 210 Consecutive Patients: A Single Center Experience.

OBJECTIVE: The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. MATERIALS AND METHODS: From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed. RESULTS: Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days. CONCLUSIONS: These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.

Laparo-endoscopic rendez-vous versus sequential "delayed" approach in patients with choledocholithiasis.

BACKGROUND: The aim of this study was to compare the efficacy and safety of synchronous laparoscopic cholecystectomy with laparo-endoscopic rendez-vous (LRV) technique vs. sequential "delayed" approach with the main goal to compare the conversion rate and postoperative complications. METHODS: Patients diagnosed as having gallstones and CBD stones or sludge were enrolled in this study. From January 2013 to June 2015, 43 consecutive patients were submitted to the sequential treatment (ERCP prior to laparoscopic cholecystectomy) and the next consecutive 46 patients were submitted to undergo the rendez-vous technique. All endoscopic procedures in both groups were performed by the same endoscopist with the same technique. Data were collected on patient age, gender, latency operation time, duration of surgery, bilio-pancreatic events, hospital stay, mortality, conversion rate and postoperative complications. RESULTS: The overall mean age was 58 years-old (25-84 years) with 43 males (48.3%) and 46 females (51.7%). The conversion rate to open surgery was 11.6% in the "sequential group" vs. 2.2% in the LRV group with a P value 0.10. The reasons for conversion included in the first group unclear anatomy (in 2 patients) and severe adhesions (in the remnant 3 patient), and in the second group unclear anatomy (in one patient). No bilio-pancreatic events occurred in the waiting period for LC in the first group. No mortality was recorded in either group. Postoperative complications were seen in 7% of patients in the "sequential group" vs. 2.2% in the rendez-vous group (P value 0.35). CONCLUSIONS: LRV does not present real advantages in comparison to delayed sequential approach in terms of conversion rate and postoperative complications. However, these results require further elaboration in studies on large numbers of patients undergoing LRV approach.