Management of groin hernias in emergency setting: differences in indications and outcomes between laparoscopic and open approach. A single-center retrospective experience.

PURPOSE: The use of minimally invasive groin hernia repair techniques in an emergency setting is still debated and its widespread is limited. The aim of this study is to evaluate the safety and efficacy of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of inguinal and femoral hernias in emergency setting based on our experience, comparing indications and outcomes with the open technique. METHODS: A retrospective analysis was performed including all patients with incarcerated and/or strangulated groin hernia who underwent emergency surgery from November 2019 to September 2022. Perioperative variables and short- and long-term outcomes were examined. Statistical analysis was performed using chi-square test for nominal variables and Student's t test for continuous ones. A p value < 0.05 was considered statistically significant. RESULTS: Sixty-six patients were included: 29 patients were treated with TAPP technique (Tapp group) and 37 with open technique plus diagnostic laparoscopy (Open group). Patients in the TAPP group were younger, had less severe clinical scenarios, and had a trend for lower Charlson Comorbidity Index, whereas ASA score and BMI were similar. The small bowel was more frequently herniated in the open group. Bilateral hernia repair was performed in 20.69% of patients in the Tapp group versus 0% in the Open group (p = 0.004). Bowel resection was more frequent in the open group (48.65% vs 0% of the Tapp group, p < 0.001) length of surgery was comparable in the two groups. In the Tapp group, the length of hospitalization was significantly shorter (2.59 ± 2.28 days vs. 9.08 ± 14.48 days; p = 0.023). Postoperative complications, according to Clavien-Dindo, were more severe in Open group where there were two deaths. There were no differences in the number of readmission and re-operations at 30 days and in the recurrence rate. CONCLUSIONS: Emergency repair of inguinal and femoral hernias using TAPP is a valuable option, safe and feasible in selected patients. In this series, indications for TAPP were reserved to younger patients with less comorbidities and less severe clinical scenario. Future randomized studies are needed to compare TAPP with open emergency hernia surgery in all settings. Potential advantages of TAPP are the reduction of postoperative complications, earlier recovery, and the possibility of bilateral treatment.

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey.

BACKGROUND: The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study. METHODS: This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection. RESULTS: Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010). CONCLUSION: Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

ANTECEDENTES: El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional. MÉTODOS: Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non-cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección. RESULTADOS: Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post-hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92-0,41; P = 0,096) y de PHLF (OR 7,13; i.c. del 95% 0,91-323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08-48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14-0,76; P = 0,010) pacientes CL. CONCLUSIÓN: La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.

Enhanced electrokinetic remediation of multi-contaminated dredged sediments and induced effect on their toxicity.

Electrokinetic (EK) remediation is often developed for metal decontamination but shows limitations for polycyclic aromatic hydrocarbons (PAHs) and polychlorobiphenyls (PCBs) which are nonionic and involve low aqueous solubility. This paper reports many laboratory studies devoted to the investigations of EK efficiency on the mobility and the removal of metals, PAHs and PCBs from dredged sediments, using a mixture of chelating agent and surfactants. The results showed that increasing chelating agent concentration was favorable for both metal and PAH removal. Applying a periodic voltage gradient associated to a low concentration of additives provided the best removal of Zn, Cd and Pb and also the 16 priority PAHs. The tested fresh harbor sediment was highly resistant to metals and organics mobilization and transport because of an aged contamination, a high buffering capacity, a very low hydraulic permeability and a high organic matter content. However, experiments performed on a former sediment which was deposited many years ago provided better removal results, involving low organic matter and carbonates content. The efficiency of the EK process was also assessed by measuring the acute toxicity of the EK-treated sediment on the copepod Eurytemora affinis exposed to sediment elutriates.

Peritoneal perforation is less a complication than an expected event during transanal endoscopic microsurgery: experience from 194 consecutive cases.

BACKGROUND: Indications for transanal endoscopic microsurgery (TEM) have been extended to technically challenging tumors, which may be associated with an increased risk of peritoneal perforation (PP). The aim of the present study was to investigate the occurrence, management and outcome of PP in patients having TEM. METHODS: All the patients who had TEM for rectal adenoma or adenocarcinoma in our unit were included. Patients in whom PP occurred (Group A) were compared to those without PP (Group B). RESULTS: From 2007 to 2015, 194 TEM (116 men, median age 66 [range 21-100] years) were divided into Groups A (n = 28, 14%) and B (n = 166). The latter group included four patients, in whom a laparoscopy did not confirm suspicion of PP made during TEM. In 2 of 28 patients (7%), the diagnosis of PP was made postoperatively during reoperation for peritonitis. For the 26 other patients (93%), routine exploratory laparoscopy was performed with suture of the peritoneal defect on the pouch of Douglas in 24 cases and a rectal suture alone in 2 cases. Independent predictive factors for PP were: distance from the anal verge >10 cm (OR = 3.6), circumferential tumor (OR = 3.0) and anterior location (OR = 2.7). Hospital stay was significantly longer in Group A (7.5 [3-31] days) than in Group B (4 [1-38] days; p < 0.0001), whereas there was no significant difference regarding postoperative morbidity and recurrence rate. CONCLUSIONS: Our results suggested that PP is not a very rare event during TEM, especially in anterior, circumferential and/or high rectal tumors. Laparoscopic treatment of PP is feasible and safe. The occurrence of PP is not associated with poor oncologic results.

Application of a crustacean bioassay to evaluate a multi-contaminated (metal, PAH, PCB) harbor sediment before and after electrokinetic remediation using eco-friendly enhancing agents.

Electrokinetic (EK) remediation can be a suitable technology for treating contaminated dredged harbor sediment, stored on terrestrial disposal sites. Citric acid (CA) and biosurfactants (rhamnolipids and saponin) were chosen as enhancing agents for simultaneous metal (Cd, Cr, Cu, Pb, Zn) and PAH/PCB removal by EK because of their potential low toxicity with a view to site restoration. Three EK runs were performed using a periodic voltage (1Vcm-1) and various concentrations of agents. The best combination of CA (0.2molL-1) and saponin (0.85gL-1) did not remove high amounts of metals (4.4-15.8%) and provided only slightly better results for PAH and PCB removal (29.2% and 38.2%, respectively). The harbor sediment was highly resistant to metal and organics mobilization and transport because of an aged contamination, a high buffering capacity, a very low hydraulic permeability and a high organic matter content. The efficiency of the EK process was also assessed by measuring the acute toxicity of the EK-treated sediment on E. affinis copepods exposed to sediment elutriates. Fortunately, the use of CA and biosurfactants did not significantly impact on sediment toxicity. Some treated sediment sections, particularly those near the anode compartment, were statistically more toxic than the raw sediment. More particularly, E. affinis copepods were significantly sensitive to low pH values and oxidative conditions, to Cu, and to a lesser extent to Pb amounts. The speciation of these metals probably changed in these pH and redox conditions so that they became more easily leachable and bioavailable. In contrast, toxicity was negatively correlated to PAH and PCB amounts after EK treatment, probably due to the production of oxidized metabolites of PAHs and PCBs.

Is there a limit to transanal endoscopic surgery? A comparative study between standard and technically challenging indications among 168 consecutive patients.

AIM: To assess the surgical outcome of transanal endoscopic surgery (TES) for rectal neoplasms in technically challenging indications. METHOD: All patients who underwent TES for a rectal neoplasm from 2007 to 2014 were included. Technically challenging indications included a tumour with (i) diameter ≥ 5 cm, (ii) involving ≥ 50% of the rectal circumference and (iii) located ≥ 10 cm from the anal verge. Patients were divided into three groups according to how many of these features they had, as follows: Group 1, none; Group 2, one; Group 3, two or more. RESULTS: Of the 168 patients (80 benign and 88 malignant tumours) included in the study, 73 (44%) were in Group 1, 46 (27%) in Group 2 and 49 (29%) in Group 3. There was no difference between Group 1 and Group 2 with regard to peritoneal perforation (P = 0.210), severe postoperative morbidity (P = 0.804), length of hospital stay (P = 0.444), incomplete resection (P = 0.441), piecemeal resection (P = 0.740), locoregional recurrence (P = 0.307) and long-term symptomatic rectal stenosis (P = 0.076). Conversely Group 3 showed significantly impaired results compared with Group 1 with regard to peritoneal perforation (P = 0.003), piecemeal resection (P = 0.005), incomplete resection (P = 0.025), locoregional recurrence (P = 0.035) and long-term symptomatic rectal stenosis (P < 0.001), but no difference in severe postoperative morbidity (P = 0.328). CONCLUSION: Transanal endoscopic surgery for rectal neoplasms appears to be safe and effective, even in patients presenting with a technically challenging tumours. Although the short- and long-term outcomes after TES are worse in patients with highly challenging tumours, nevertheless the technique should still be considered in patients at high risk of requiring a proctectomy.

[Pancreatic carcinoma presenting with invasion of the vena porta or the superior mesenteric vein: our experience and review of the literature]. / Carcinoma del pancreas con infiltrazione della vena porta o della vena mesenterica superiore: nostra esperienza e revisione della letteratura.

AIM: Adenocarcinoma of the pancreas can present with invasion of the vena porta or the superior mesenteric vein (SMV). Pancreatectomy with resection of the vena porta and/or the SMV remains controversial although the procedure is potentially curative. The aim of this study was to validate the indication for resection on the basis of our experience and evidence from recently published studies. METHODS: Studies published in the last 10 years on pancreatectomy (duodenocephalopancreatectomy, total and distal pancreatectomy) with resection of the vena porta and/or the SMV were retrieved from the Medline database and reviewed. A total of 18 studies meeting the inclusion criteria were analyzed for information about indications, type of intervention, use of adjuvant therapies, histopathology, perioperative results and survival in 620 patients with adenocarcinoma of the pancreas undergoing pancreatectomy with resection of the vena porta and the SMV. This data set was then compared with our experience with this procedure from the last 3 years. RESULTS: The mortality and postoperative complication rates varied between 0% and 7.7% and 12.5% and 54%, respectively. The median survival varied from 12 to 22 months; the 1 year survival rate was between 31% and 83%; the 5-year survival rate was between 9 and 18% according to the studies reviewed. CONCLUSION: On the basis of evidence from the literature and our experience, en bloc resection of the vena porta and/or the SMV during pancreatectomy appears to be a safe procedure with acceptable outcomes, and should be considered in patients with pancreatic cancer presenting with venous invasion. Venous resection increases the surgical cure rate, prolonging survival in patients selected according to correct indications.

Spigelian hernia: a case report and review of the literature.

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.