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The laparoscopic approach represents the standard of treatment for renal and adrenal diseases, and its use is increasing even outside referral centres. Although most procedures are routinely performed, intraoperative complications do not occur, and the rate and predictive factors of these complications have not been established. The aim of this study was to evaluate the incidence and type of intraoperative complications and to identify predictive factors in patients undergoing laparoscopic renal and adrenal surgery. This was a cohort, multicentre, international retrospective study. Patients who underwent laparoscopic renal and adrenal surgeries between April 2017 and March 2022 were included in the study. Bivariate analysis was performed using contingency tables and the χ2 test for independent samples to compare qualitative variables and the T test and Mood test for continuous variables. Multivariate analysis was performed using a logistic regression model to obtain adjusted odds ratios. A total of 2374 patients were included in the study. Intraoperative complications were reported for 8.09% of patients who underwent renal surgery, with the most common complications reported being hollow viscus and vascular complications, and for 6.75% of patients who underwent adrenal surgery, with the most common complication reported being parenchymatous viscous complications. Multivariate analysis revealed that both adrenal and renal surgery radiological preoperative factors, such as invasive features during adrenalectomy and the RENAL score during nephrectomy, are predictive factors of intraoperative complications. In contrast to existing data, surgeon experience was not associated with a reduction in the incidence of perioperative complications.
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Laparoscopía , Humanos , Estudios Retrospectivos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Adrenalectomía/efectos adversos , Adrenalectomía/métodos , Nefrectomía/efectos adversos , Nefrectomía/métodos , Complicaciones Intraoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
OBJECTIVES: In this study, we investigated the role of several circulating and drainage fluid biomarkers for detecting postoperative complications (PCs) and anastomotic leakage (AL) in patients undergoing colorectal surgery. METHODS: All consecutive patients undergoing colorectal surgery between June 2018 and April 2020 were prospectively considered. On postoperative days (POD) 1, 3, and 5, we measured lactate dehydrogenase (LDH) in drainage fluid, C-reactive protein (CRP) in serum and drainage fluid, and neutrophil to lymphocyte ratio (NLR). RESULTS: We enrolled 187 patients. POD1 patients with AL had higher serum CRP levels, while on POD3 and on POD5 higher NLR and serum CRP. LDH and CRP in drainage fluid were also significantly higher at both time points. The area under the curves (AUCs) of serum and drainage fluid CRP were 0.752 (0.629-0.875) and 0.752 (0.565-0.939), respectively. The best cut-off for serum and drainage fluid CRP was 185.23 and 76â¯mg/dL, respectively. The AUC of NLR on POD3 was 0.762 (0.662-0.882) with a sensitivity and specificity of 84 and 63â¯%, respectively, at a cut-off of 6,6. Finally, drainage fluid LDH showed the best diagnostic performance for AL, with an AUC, sensitivity, and specificity of 0.921 (0.849-0.993), 82â¯%, and 90â¯% at a cut-off of 2,186â¯U/L. Trends in serum parameters between patients with or without PCs or AL were also evaluated. Interestingly, we found that NLR decreased faster in patients without PCs than in patients with PCs and patients with AL. CONCLUSIONS: Drainage fluid LDH and NLR could be promising biomarkers of PCs and AL.
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Fuga Anastomótica , Cirugía Colorrectal , Humanos , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/etiología , Neutrófilos/metabolismo , Biomarcadores , Proteína C-Reactiva/análisis , Linfocitos/metabolismo , Drenaje/efectos adversos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal tract. We describe our experience with a patient with gastric perforation and concomitant gastric haemorrhage with severe anaemia, in whom we successfully extracted a giant gastric phytobezoar by cooperative laparoscopic and endoscopic surgery. CASE PRESENTATION: A 68-year-old man was admitted with melena and septic shock. CT scan revealed a gastric perforation. We performed a combined laparoscopic and endoscopic approach with gastrotomy, removal of the phytobezoar and laparoscopic gastric suture. The suture was examined for leakage with the endoscopic hydropneumatic test to obtain direct vision of the suture and no evidence of leakage by insufflation of the area. DISCUSSION: Gastric bezoars can be managed conservatively, endoscopically or surgically. Endoscopic removal, if effective, would be an attractive alternative for bezoar treatment. Usually endoscopic attempts are unsuccessful because of the large size of the bezoar and the difficulty in fragmentation. The laparoscopic approach for bezoar seems to have better postoperative outcomes. The main criticisms of the technique are abdominal spillage with risk of contamination as well as longer operative times. CONCLUSION: In our case we simultaneously performed laparoscopic surgery and endoscopic operative procedure in accordance with the principles of laparoscopic and endoscopic cooperative surgery to treat the gastric bezoar in order to overcome the limits of a single technique.
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BACKGROUND: Compared to other types of abdominal protrusions, Spigelian hernias are not very common. In prosthetic repair of abdominal protrusions, mesh fixation and defect overlap are an open issue, as they are a source of complications. A newly developed tentacle-shaped mesh has been used to ensure a fixation-free repair with a broader defect overlap in the repair of abdominal hernias. This study describes the long-term results of a fixation-free repair of Spigelian hernias carried out with a tentacle mesh. METHODS: A proprietary mesh composed of a central body with integrated radiating arms was used for repairing Spigelian hernias in 54 patients. The implant was positioned in preperitoneal sublay, and the straps were delivered across the abdominal musculature with a needle passer, and then, after fascia closure, cut short in the subcutaneous layer. RESULTS: The friction of the straps passing through the abdominal wall served to hold the mesh in place, guaranteeing a wide overlap over the defect without fixation. In a long-term follow-up of 6 to 84 months (mean 64 months), a very low rate of complications occurred, but no recurrence was reported. CONCLUSIONS: The tentacle strap system of the prosthesis allowed for an easy, fast and safe fixation-free placement granting a wide overlap, avoiding intraoperative complications. Greatly reduced pain and a negligible amount of postoperative complications characterized the postoperative outcome.
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Surgical repair of groin protrusions is one of the most frequently performed procedures. Currently, open or laparoscopic repair of inguinal hernias with flat meshes deployed over the hernial defect is considered the gold standard. However, fixation of the implant, poor quality biologic response to meshes and defective management of the defect represent sources of continuous debates. To overcome these issues, a different treatment concept has recently been proposed. It is based on a 3D scaffold named ProFlor, a flower shaped multilamellar device compressible on all planes. This 3D device is introduced into the hernial opening and, thanks to its inherent centrifugal expansion, permanently obliterates the defect in fixation-free fashion. While being made of the same polypropylene material as conventional hernia implants, the 3D design of ProFlor confers a proprietary dynamic responsivity, which unlike the foreign body reaction of flat/static meshes, promotes a true regenerative response. A long series of scientific evidence confirms that, moving in compliance with the physiologic cyclical load of the groin, ProFlor attracts tissue growth factors inducing the development of newly formed muscular, vascular and nervous structures, thus re-establishing the inguinal barrier formerly wasted by hernia disease. The development up to complete maturation of these highly specialized tissue elements was followed thanks to biopsies excised from ProFlor from the short-term up to years post implantation. Immunohistochemistry made it possible to document the concurrence of specific growth factors in the regenerative phenomena. The results achieved with ProFlor likely demonstrate that modifying the two-dimensional design of hernia meshes into a 3D outline and arranging the device to respond to kinetic stresses turns a conventional regressive foreign body response into advanced probiotic tissue regeneration.
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INTRODUCTION: Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies. METHODS: We used the MESH terms "appendicitis" AND "situs inversus" AND/OR "gut malrotation" to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data. RESULTS: We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener's syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition. CONCLUSION: Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.
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Radiografía , Humanos , Femenino , Masculino , Niño , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Enfermedad Aguda , Diagnóstico DiferencialRESUMEN
BACKGROUND: The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection. METHODS: We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons. RESULTS: Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field. CONCLUSION: The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.
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Neoplasias del Colon , Laparoscopía , Mesocolon , Humanos , Masculino , Neoplasias del Colon/diagnóstico por imagen , Neoplasias del Colon/cirugía , Angiografía por Tomografía Computarizada , Estudios Prospectivos , Colectomía/métodos , Ligadura/métodos , Laparoscopía/métodos , Mesocolon/diagnóstico por imagen , Mesocolon/cirugía , Escisión del Ganglio Linfático/métodos , Complicaciones Intraoperatorias , Resultado del TratamientoRESUMEN
Luteinised unruptured follicle syndrome (LUFS) is a cause of infertility consisting in the unruptured of the dominant follicle after the LH-surge. In fact, during assisted reproductive treatments (ART) clomiphene citrate and letrozole are frequently administered in order to achieve ovulation. However, considering the pathophysiology of LUFS, new possible therapy can be proposed. On this scenario, we performed a review of the literature searching for LUFS recurrency and its impact in infertility and ART. An inflammation theory has been proposed that can be fuel for further therapeutic possibilities. In particular, considering the increase in granulocytes accumulation, the granulocyte colony-stimulating factor (G-CSF) administration has been proposed as target therapy in IUI cycles hampered by LUFS. Although data are encouraging, randomised controlled trials are needed in order to confirm the efficacy of G-CSF administration for LUFS patients.
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Factor Estimulante de Colonias de Granulocitos , Infertilidad Femenina , Enfermedades del Ovario , Ovulación , Femenino , Humanos , Factor Estimulante de Colonias de Granulocitos/farmacología , Infertilidad Femenina/etiología , Enfermedades del Ovario/complicaciones , Ovulación/efectos de los fármacos , Inducción de la Ovulación , Técnicas Reproductivas Asistidas/efectos adversosRESUMEN
PURPOSE: This retrospective multicenter cohort study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective laparoscopic cholecystectomy (LC) when performed by a surgical resident in comparison to experienced consultant in the backdrop of Italian academic centers. METHODS: Retrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant or senior resident. Main outcome was complication rates (intraoperative and peri/postoperative); secondary outcomes included operative time, the length of stay, and the rate of conversion to open. RESULTS: A total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs (72%), while the residents performed 648 (28%) surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications. The rate of conversion to open cholecystectomy was 1.42% for consultant and none for resident (p = 0.02). A statistically significant difference was observed between groups regarding the average length of stay (2.2 ± 3 vs 1.6 ± 1.3 days p = 0.03). Similarly, postoperative complications (1.7% vs 0.5%) resulted in statistically significant (p = 0.02) favoring resident group. CONCLUSIONS: Our study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons.
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Colecistectomía Laparoscópica , Internado y Residencia , Femenino , Humanos , Colecistectomía Laparoscópica/métodos , Estudios Retrospectivos , Estudios de Cohortes , Colecistectomía/métodos , Complicaciones Posoperatorias/epidemiologíaRESUMEN
Laparoscopic TAPP/TEP approaches are well-established options for the cure of inguinal hernias. As in the open approach, mesh fixation and poor-quality biologic response represent controversial questions and are a source of concerns. Furthermore, hernia defect patency represents another problem which seems not well acknowledged among surgeons. These problems are considered the cause of frequent intra and postoperative complications. To overcome these concerns, recently a different concept of cure has emerged. Based on a newly developed dynamic responsive 3D scaffold named ProFlor, a permanent hernia defect obliteration has been finalized. Following its inherent centrifugal expansion due to its dynamic responsivity, this hernia device is positioned fixation free within the defect and induces a probiotic biological response allowing for the re-establishment of the degenerated inguinal barrier. A laparoscopic approach with the 3D scaffold has been tested on 71 patients to demonstrate its effectiveness in reducing intra and postoperative complications. The operated patients presented with bilateral and/or recurrent inguinal hernia. Overall, 122 hernia defects were obliterated with 119 dynamic responsive scaffolds. The procedures were carried out from January 2018 to January 2022 with a defined protocol and detailed procedural steps. The laparoscopic technique with the 3D hernia scaffold allowed for fixation free placement, permanent defect obliteration and dynamically induced regenerative effects. The technique proved effective in reducing intra and postoperative complications. In particular, early postoperative pain and discomfort significantly decreased. No chronic pain and no recurrences were reported during follow up. The results achieved with the described laparoscopic technique seem to embody an innovative concept for inguinal hernia repair. Fixation free, dynamic responsive, permanent defect obliteration, histologically proven regenerative effects are the distinctive features of this 3D scaffold. It seems to embody a more physiological and pathogenetically coherent concept of cure, thus improving treatment results of this widespread disease.
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Hernia Inguinal , Laparoscopía , Humanos , Hernia Inguinal/cirugía , Herniorrafia/efectos adversos , Mallas Quirúrgicas , Laparoscopía/métodos , Resultado del Tratamiento , Complicaciones Posoperatorias/etiologíaRESUMEN
Endometriosis is a disease affecting approximately 10% of women of fertile age. A particular presentation is deep infiltrating endometriosis of the rectosigmoid colon with symptoms that can mimic an intestinal obstruction or neoplasm. We report the case of a 39-year-old woman with pelvic pain during the menstrual cycle and significant anemia who presented an ectopic endometrial tissue in correspondence of the rectum. Because of the thickness of the lesion the patient underwent a segmental laparoscopic colorectal resection with end-to-end anastomosis.
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BACKGROUND: Postoperative chronic pain caused by fixation and/or fibrotic incorporation of hernia meshes are the main concerns in inguinal herniorrhaphy. As inguinal hernia is a degenerative disease, logically the treatment should aim at stopping degeneration and activating regeneration. Unfortunately, in conventional prosthetic herniorrhaphy no relationship exists between pathogenesis and treatment. To overcome these incongruences, a 3D dynamic responsive multilamellar scaffold has been developed for fixation-free inguinal hernia repair. Made of polypropylene like conventional flat meshes, the dynamic behavior of the scaffold allows for the regeneration of all typical inguinal components: connective tissue, vessels, nerves, and myocytes. This investigation aims to demonstrate that, moving in tune with the groin, the 3D scaffold attracts myogenic growth factors activating the development of mature myocytes and, thus, re-establishing the herniated inguinal barrier. METHODS: Biopsy samples excised from the 3D scaffold at different postoperative stages were stained with H&E and Azan-Mallory; immunohistochemistry for NGF and NGFR p75 was performed to verify the degree of involvement of muscular growth factors in the neomyogenesis. RESULTS: Histological evidence of progressive muscle development and immunohistochemical proof of NFG and NFGRp75 contribution in neomyogenesis within the 3D scaffold was documented and statistically validated. CONCLUSION: The investigation appears to confirm that a 3D polypropylene scaffold designed to confer dynamic responsivity, unlike the fibrotic scar plate of static meshes, attracts myogenic growth factors turning the biological response into tissue regeneration. Newly developed muscles allow the scaffold to restore the integrity of the inguinal barrier.
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Introduction: Bowel perforation is a relatively rare presentation of abdominal tuberculosis, whose diagnosis is challenging but fundamental to minimize morbidity and mortality. Laparoscopy is considered an effective modality for diagnosis, but its role in surgical treatment is still not established. We reported the first worldwide case of totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation. Case presentation: A 30-year-old man with a history of weight loss, preceded by 2 years of nonproductive cough, was admitted to the Infectious Disease Department with a presumed diagnosis of tuberculosis. A microbiological culture test confirmed the diagnosis, and the patient undertook quadruple antituberculous therapy. During hospitalization, he presented sudden abdominal pain, fever, and vomit. An abdominal CT scan showed small bowel perforation with granulomatous reaction. Laparoscopy was performed and revealed a 2â cm perforation on the medium ileum. Small bowel resection and totally intracorporeal side-to-side anastomosis were performed. No complication occurred until a clinical follow-up of 2 months. Conclusion: In consideration of the increasing incidence of intestinal TB in both underdeveloped and Western countries, the diagnosis of this pathology should be taken into account in high-risk patients. Probably, the diagnostic challenges and emergency settings of intestinal TB with perforation and peritonitis, together with the lack of standardized guidelines regarding surgical management, make the use of laparoscopy apparently arduous, but the known advantages of laparoscopy and its technical feasibility should make it a conceivable option for the treatment of complicated cases.
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INTRODUCTION: Klippel-Trenaunay syndrome is an uncommon congenital disease also called angio-osteodystrophy syndrome for its typical disorders characterized by abnormal growth of the soft tissues and bones and vascular malformations. CASE REPORT: In this report, we present a rare case of a 46-year-old nulliparous woman with Klippel-Trenaunay syndrome. She suffered from an abnormal uterine bleeding accompanied by severe anemia with need for multiple blood transfusions. At the time of admission, physical examination revealed port-wine stains and varicose veins on her lower limbs and hypertrophy of left lower extremity. We carried out an open bilateral hysteroannexectomy. Histopathology examination revealed a uterus weighing 6300 g with diffuse abnormal vasculature, leiomyomatosis and diffuse venous malformation. DISCUSSION: Klippel-Trenaunay syndrome is considered a rare disease as it has an incidence of 2-5 on 100,000 with no differences between the both sexes. The clinical manifestations are related to the organs involved in the pathological angiogenesis therefore patients may also present cerebral, retinal, gastrointestinal and genitourinary anomalies with consequent occult or significant bleeding. Uterine involvement is very rare. The main clinical manifestations are represented by irregular episodes of hematuria and/or menometrorrhagia associated with important anatomical anomalies of the female reproductive system. CONCLUSION: Uterine involvement in patients with Klippel-Trenaunay syndrome, althought rare and with extremely variable clinical manifestations, is actually a relevant event that not only significantly affects the reproductive capacity of the woman but which potentially puts patients' lives at risk because of an unpredictable bleeding.
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Introduction: Klippel-Trenaunay syndrome (KTS) is a rare vascular congenital disorder characterized by the classical triad of port-wine stains, abnormal growth of soft tissues and bones, and vascular malformations. The involvement of the genitourinary tract and of the uterus in particular is extremely infrequent but relevant for possible consequences. Methods: We performed an extensive review of the literature using the Pubmed, Scopus and ISI web of knowledge database to identify all cases of KTS with uterine involvement. The search was done using the MeSH term "Klippel-Trenaunay syndrome" AND "uterine" OR "uterus." We considered publications only in the English language with no limits of time. We selected a total of 11 records of KTS with uterine involvement, including those affecting pregnant women. Results: Klippel-Trenaunay syndrome was described for the first time in the year 1900 in two patients with hemangiomatous lesions of the skin associated with varicose veins and asymmetric soft tissue and bone hypertrophy. Uterine involvement is a rare condition and can cause severe menorrhagia. Diagnosis is based on physical signs and symptoms. CT scans and MRI are first-choice test procedures to evaluate both the extension of the lesion and the infiltration of deeper tissues before treatment. The management of Klippel-Trenaunay syndrome should be personalized using careful diagnosis, prevention and treatment of complications. Conclusion: Klippel-Trenaunay syndrome is a rare vascular malformation with a wide variability of manifestations. There are no univocal and clear guidelines that suggest the most adequate monitoring of the possible complications of the disease. Treatment is generally conservative, but in case of recurrent bleeding, surgery may be needed.
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BACKGROUND: Inguinal hernia is a degenerative disease occurring in a high motile surround. Stopping degeneration and promoting tissue regeneration should be the treatment goal. Groin hernias are conventionally managed with static flat meshes, mostly fixated to the delicate inguinal environment. Far from a regenerative effect, the biologic response of conventional hernia meshes is characterized by a foreign body reaction leading to a stiff/shrunken scar plate, which is often the source of unpleasant complications. Recently, a newly engineered 3D device for inguinal hernia repair - ProFlor-has been developed to produce a regenerative biological response. Unlike conventional hernia meshes, this regenerative 3D hernia scaffold seems to demonstrate suitable features for a pathogenetical and physiological coherent treatment of the disease. The aim of this manuscript is to cross evidence these features through magnetic resonance imaging (MRI) and histology. STUDY DESIGN: The biological response of ProFlor at three defined post-implantation stages has been evaluated through MRI signal intensity and compared to neighbouring muscles and fat. As additional proof, histology of tissue specimens excised at the same post-implantation periods from porcine models during an experimental attempt were also evaluated. RESULTS: MRI of newly ingrown tissue in ProFlor demonstrated similar signal intensity of muscles while fat tissue showed remarkably higher values. These data matched with the histology of ProFlor biopsies excised from pigs. CONCLUSIONS: The motile compliance to groin movements of ProFlor appears to induce a probiotic biologic response comparable to a regenerative scaffold, allowing to physiologically resolve the degenerative source of inguinal hernia disease.
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Hernia Inguinal , Animales , Ingle/cirugía , Hernia Inguinal/diagnóstico por imagen , Hernia Inguinal/cirugía , Herniorrafia , Imagen por Resonancia Magnética , Mallas Quirúrgicas , PorcinosRESUMEN
BACKGROUND: Perioperative management of pheochromocytoma (PCC) remains under debate. METHODS: A bicentric retrospective study was conducted, including all patients who underwent laparoscopic adrenalectomy for PCC from 2000 to 2017. Patients were divided into two groups: Group 1 treated with alpha-blockade, and Group 2, without alfa-blockers. The primary end point was the major complication rate. The secondary end points were: the need for advanced intra-operative hemostasis, the admission to the intensive care unit (ICU), the length of stay (LOS), systolic (SBP), and diastolic blood pressure (DBP). Univariate and multivariate analysis was conducted. A p-value < 0.05 was considered statistically significant. RESULTS: Major postoperative complications were similar (p = 0.49). Advanced hemostatic agents were 44.9% in Group 1 and 100% in Group 2 (p < 0.001). In Group 2, no patients were admitted to the ICU, while only 73.5% of Group 1 (p < 0.001) were admitted. The median length of stay was larger in Group 1 than in Group 2 (p = 0.026). At the induction, SBP was 130 mmHg in Group 1, and 115 mmHg (p < 0.001). The pre-surgery treatment was the only almost statistically significant variable at the multivariate analysis of DBP at the end of surgery. CONCLUSION: The preoperative use of alfa-blockers should be considered not a dogma in PCC.
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Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold-ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)-that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.
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Hernia Inguinal , Ingle/cirugía , Hernia Inguinal/cirugía , Herniorrafia , Humanos , Dolor Postoperatorio , Prótesis e Implantes , Recurrencia , Mallas QuirúrgicasRESUMEN
Biologic response to hernia prostheses represents a continuous source of debate. Conventional hernia meshes, in their typical static, passive configuration have been used for decades to reinforce the herniated abdominal wall. These flat implants, mainly fixated with sutures or tacks, induce poor quality fibrotic ingrowth that shrinks the mesh. In groin hernia repair, flat meshes are applied in the delicate inguinal surrounding where uncontrolled development of a scar plate can impair movement and may incorporate the sensitive nerves crossing this area. Complications deriving from mesh fixation and nerve entrapment are frequent and unpleasant for patients. To remedy these problems, a multilamellar shaped 3D device with a dynamic responsive behavior has recently been developed to repair inguinal hernia. Its inherent dynamic compliance during inguinal movements has shown to induce enhanced biological response with ingrowth of newly formed connective tissue, muscle fibers, and nerves. The function of these highly specialized tissue structures is supported by the contextual development of newly formed arteries and veins. The scope of the study was to assess quantity and quality of vessels, which had ingrown in the 3D hernia device in the short-term, medium-term, and long-term post-implantation, in biopsy specimens gathered from inguinal hernia patients operated with the 3D device. Starting from an early stage, widespread angiogenesis was evident within the 3D structure. Arteries and veins increased in quantity showing progressive development until full maturation of all specific vascular components throughout the mid-term, to long-term, post-implantation. High quality biologic ingrowth in hernia prosthetics needs an adequate vascular support. The broad network of mature arteries and veins evidenced herewith seems to confirm the enhanced biological features of the dynamic responsive 3D device whose features resemble a regenerative scaffold, an ideal feature for the treatment of the degenerative source of inguinal hernia disease.