Does the visceral fat area impact the histopathology specimen metrics after total mesorectal excision for distal rectal cancer?

BACKGROUND: The aim of this study was to evaluate whether the visceral fat area (VFA) has an impact on the histopathology specimen metrics of male patients undergoing robotic total mesorectal resection (rTME) for distal rectal cancer. METHODS: Prospectively collected data of patients undergoing rTME for resectable rectal cancer by five surgeons during a period of three years were extracted from the REgistry of Robotic SURgery for RECTal cancer (RESURRECT). VFA was measured in all patients at preoperative computed tomography. Distal rectal cancer was defined as <6cm from the anal verge. The histopathology metrics included circumferential resection margin (CRM) (in mm) and its involvement rate (if <1mm), distal resection margin (DRM), and quality of TME (complete, nearly-complete, incomplete). RESULTS: Of 839 patients who underwent rTME, 500 with distal rectal cancer were included. One hundred and six (21.2%) males with VFA>100cm2 were compared to 394 (78.8%) males or females with VFA≤100cm2. The mean CRM of males with VFA>100cm2 was not significantly different from its counterpart (6.6 ± 4.8 mm versus 7.1 ± 9.5mm; p=0.752). CRM involvement rates were 7.6% in both groups (p=1.000). The DRM was not significantly different: 1.8±1.9cm versus 1.8±2.6cm; p=0.996. The quality of TME did not significantly differ: complete TME 87.3% vs. 83.7%; nearly complete TME 8.9% vs. 12.8%; incomplete TME 3.8% vs. 3.6%. Complications and clinical outcomes did not significantly differ. CONCLUSION: This study did not find evidence to support that increased VFA would result in suboptimal histopathology specimen metrics when performing rTME in males with distal rectal cancer.

Do patients' and referral centers' characteristics influence multiple sclerosis phenotypes? Results from the Italian multiple sclerosis and related disorders register.

BACKGROUND: Multiple sclerosis (MS) is characterized by phenotypical heterogeneity, partly resulting from demographic and environmental risk factors. Socio-economic factors and the characteristics of local MS facilities might also play a part. METHODS: This study included patients with a confirmed MS diagnosis enrolled in the Italian MS and Related Disorders Register in 2000-2021. Patients at first visit were classified as having a clinically isolated syndrome (CIS), relapsing-remitting (RR), primary progressive (PP), progressive-relapsing (PR), or secondary progressive MS (SP). Demographic and clinical characteristics were analyzed, with centers' characteristics, geographic macro-areas, and Deprivation Index. We computed the odds ratios (OR) for CIS, PP/PR, and SP phenotypes, compared to the RR, using multivariate, multinomial, mixed effects logistic regression models. RESULTS: In all 35,243 patients from 106 centers were included. The OR of presenting more advanced MS phenotypes than the RR phenotype at first visit significantly diminished in relation to calendar period. Females were at a significantly lower risk of a PP/PR or SP phenotype. Older age was associated with CIS, PP/PR, and SP. The risk of a longer interval between disease onset and first visit was lower for the CIS phenotype, but higher for PP/PR and SP. The probability of SP at first visit was greater in the South of Italy. DISCUSSION: Differences in the phenotype of MS patients first seen in Italian centers can be only partly explained by differences in the centers' characteristics. The demographic and socio-economic characteristics of MS patients seem to be the main determinants of the phenotypes at first referral.

Efficacy of levetiracetam on upper limb movement in multiple sclerosis patients with cerebellar signs: a multicenter double-blind, placebo-controlled, crossover study.

BACKGROUND AND PURPOSE: The literature provides contrasting results on the efficacy of levetiracetam (LEV) in multiple sclerosis (MS) patients with cerebellar signs. It was sought to evaluate the efficacy of LEV on upper limb movement in MS patients. METHODS: In this multicenter double-blind placebo-controlled crossover study, MS patients with prevalently cerebellar signs were randomly allocated into two groups: LEV followed by placebo (group 1) or placebo followed by LEV (group 2). Clinical assessments were performed by a blinded physician at T0 (day 1), T1 (day 22), T2 (2-week wash-out period, day 35) and T3 (day 56). The primary outcome was dexterity in the arm with greater deficit, assessed by the nine-hole peg test (9HPT). Secondary clinical outcomes included responders on the 9HPT (∆9HPT >20%), tremor activity of the daily living questionnaire and self-defined upper limb impairment, through a numeric rating scale. Kinematic evaluation was performed using a digitizing tablet, providing data on normalized jerk, aiming error and centripetal acceleration. RESULTS: Forty-eight subjects (45.2 ± 10.4 years) were randomly allocated into two groups (n = 24 each). 9HPT significantly improved in the LEV phase in both groups (P < 0.001). The LEV treatment phase led to a significant improvement (P < 0.01) of all clinical outcomes in group 1 and in dexterity in group 2. No significant changes were reported during both placebo phases in the two groups. Considering the kinematic analysis, only normalized jerk significantly improved after treatment with LEV (T0-T1) in group 1. CONCLUSIONS: Levetiracetam treatment seems to be effective in improving upper limb dexterity in MS patients with cerebellar signs.

Primary anastomosis and nonrestorative resection for perforated diverticulitis with peritonitis: meta-analysis of randomized trials.

AIM: The aim of this meta-analysis was to comparatively evaluate the outcomes of primary anastomosis (PRA) and nonrestorative resection (NRR) as emergency surgery and ostomy reversal in patients with perforated diverticulitis and peritonitis. METHODS: PubMed, MEDLINE via Ovid, Embase, CINAHL, Cochrane Library and Web of Science databases were systematically searched. Postoperative morbidity following emergency resection was the primary end-point. Quality assessment of the included studies was performed using the Cochrane Quality Assessment Tool including recruitment bias and crossover with intention-to-treat analysis. The Haenszel-Mantel method with odds ratios (OR, 95% CI) and the inverse variance method with mean difference (MD, 95% CI) as effect measures were utilized for dichotomous and continuous outcomes, respectively. RESULTS: Four randomized controlled trials totaling 382 patients (180 PRA vs 204 NRR) were included. Morbidity rates following emergency resection did not differ (OR = 0.99, 95% CI 0.65, 1.51; P = 0.95; number needed to treat/harm (NNT) 96). Organ/space surgical site infection rates were 3.3% in PRA vs 11.3% in NRR (OR = 0.29, 95% CI 0.12, 0.74; P = 0.009; NNT = 13). Postoperative morbidity rates following ostomy reversal were significantly lower in PRA (OR = 0.31, 95% CI 0.15, 0.64; P = 0.001; NNT = 7). Pooled ostomy non-reversal rates were 16% in PRA vs 35.5% in NRR (OR = 0.37, 95% CI 0.22, 0.62; P = 0.0001; NNT = 6) with high heterogeneity (I2  = 63%; τ2  = 8.17). Meta-regression analysis revealed significant negative correlation between the PRA-to-NRR crossover rate and the ostomy non-reversal rate (P = 0.029). CONCLUSION: This meta-analysis found that PRA was associated with better short- and long-term outcomes at the cost of significantly longer operating time at emergency surgery.

Prevalence of dysphagia in a consecutive cohort of subjects with MS using fibre-optic endoscopy.

INTRODUCTION: Multiple sclerosis (MS) refers to chronic inflammation of the central nervous system including the brain and spinal cord. Dysphagia is a symptom that represents challenges in clinical practice. The aim of the present study was to evaluate the prevalence of dysphagia in an Italian cohort of subjects with MS using the Dysphagia Outcome Severity Score (DOSS), based on fibre-optic endoscopy, and determine factors that correlate with the presence of swallowing problems. MATHERIALS AND METHODS: Data were collected in a multicentre study from a consecutive sample of MS patients, irrespective of self-reported dysphagia. The study included 215 subjects. Possible scores for DOSS range from 7 to 1, with 7 indicating normal swallowing. RESULTS: One hundred twenty-four (57.7%) subjects demonstrated abnormal swallowing and 57 (26.5%) of these had swallowing problems that required nutrition/diet modifications when evaluated objectively with fibre-optic endoscopy. Subjects with dysphagia were more severely disabled and more often had a progressive form of MS, compared to MS subjects with normal swallowing. In subjects with EDSS, < 4, 8 (13.3%), had a DOSS < 4. Seventy-five percent of subjects older than 60 years of age had dysphagia. CONCLUSION: In this sample of MS patients, more nearly 60% showed swallowing problems.

Right hemicolectomy - from laparoscopic facilitated technique to robotic intracorporeal anastomosis.

Several different operative techniques have been applied in minimally invasive right colectomy. Data reported in literature confirm the advantages of laparoscopic approach, however, there is no sure evidence of which one is the best. The pure laparoscopic technique with intracorporeal anastomosis seems to show some advantages compared to the other laparoscopic and open procedures, although for the price of technical difficulty and a longer operating time.

Purse-string vs. linear skin closure at loop ileostomy reversal: a systematic review and meta-analysis.

BACKGROUND: There is no level 1a evidence regarding the best technique for skin closure at loop ileostomy reversal. The aim of this study was to evaluate whether purse-string skin closure (PSC) is associated with lower surgical site infection (SSI) rates as compared to linear skin closure (LC). METHODS: EMBASE, MEDLINE, Pubmed, Cochrane Library, Web of Science, and CINAHL databases were systematically searched. PSC was defined as a circumferential subcuticular suture leaving a small circular skin defect allowing for free drainage, granulation, and epithelialization. In LC, the wound edges were approximated side to side with or without drainage. The primary endpoint was SSI rate. Secondary endpoints included operating time, length of hospital stay, wound healing time, and incisional hernia rates. STUDY SELECTION: Inclusion criterion was any observational or experimental study comparing PSC to LC in patients undergoing ostomy reversal. RESULTS: Twenty studies (6 experimental and 14 observational) totaling 1812 patients (826 PSC and 986 LC) were included. SSI rates were significantly lower statistically and clinically in patients with PSC [OR (95% CI) = 0.14 (0.09, 0.21); p < 0.0001; NNT = 6] in the meta-analysis of all studies. The subgroup analysis of randomized trials [OR (95% CI) = 0.10 (0.04, 0.21); p < 0.0001; NNT = 6] as well as the analysis of randomized trials including patients with loop ileostomy only [OR (95% CI) = 0.12 (0.05, 0.28); p < 0.0001; NNT = 5] confirmed this finding. CONCLUSIONS: This meta-analysis found that PSC was associated with significantly decreased rates of SSI in patients undergoing loop ileostomy reversal.

Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively.

BACKGROUND: The aim of this RCT was to determine whether elective resection following successful non-operative management of a first episode of acute sigmoid diverticulitis complicated by extraluminal air with or without abscess is superior to observation in terms of recurrence rates. METHODS: This was a single-centre, sequential design RCT. Patients were randomized to elective surgery or observation following non-operative management and colonoscopy. Non-operative management included nil by mouth, intravenous fluids, intravenous antibiotics, CT with intravenous contrast on arrival at hospital, and repeat CT with intravenous and rectal contrast on day 3 in hospital. The primary endpoint was recurrent diverticulitis at 24 months. Patients with a history of sigmoid diverticulitis, immunosuppression or peritonitis were not included. RESULTS: Of 137 screened patients, 107 were assigned randomly to elective surgery (26) or observation (81), and underwent the allocated intervention after successful non-operative management. Conservative management failed in 15 patients. Groups were similar in age, sex, BMI, co-morbidities and colorectal POSSUM. Rates of recurrent diverticulitis differed significantly in the elective surgery and observation groups (8 versus 32 per cent; P = 0·019) at a mean(s.d.) follow-up of 37·8(8·6) and 35·2(9·2) months respectively. There was also a significant difference in time to recurrence (median 11 versus 7 months; P = 0·015). A total of 28 patients presented with recurrent diverticulitis complicated by extraluminal air and/or abscess (2 elective surgery, 26 observation), all of whom recovered with repeat non-operative management. CONCLUSION: The majority of patients observed following conservative management of diverticulitis with local extraluminal air do not require elective surgery. Registration number: NCT01986686 (http://www.clinicaltrials.gov).

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study.

AIM: Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn's ileitis and overweight patients with right colon tumors. METHOD: This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn's terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery. RESULTS: Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p = 0.294), gender (p = 0.683), ASA (p = 0.545), BMI (p = 0.079), previous abdominal surgery (p = 0.348), and diagnosis (p = 0.301). Conversion rates (5.1 vs. 3.6%; p = 0.457) and intraoperative complications (1 vs. 2.1%; p = 0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p = 0.008) and re-intervention rates (3.1 vs. 8.7%; p = 0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p = 0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p = 0.01). CONCLUSION: Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis.

AIM: It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD: The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS: Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION: This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.

Laparoscopic approaches to complicated diverticulitis.

BACKGROUND: The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE: The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS: New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

Perioperative hyperglycemia: an unmet need within a surgical site infection bundle.

BACKGROUND: The aim of this study was to determine whether perioperative stress hyperglycemia is correlated with surgical site infection (SSI) rates in non-diabetes mellitus (DM) patients undergoing elective colorectal resections within an SSI bundle. METHODS: American College of Surgeons National Surgical Quality Improvement Program data of patients treated at a single institution in 2006-2012 were supplemented by institutional review board-approved chart review. A multifactorial SSI bundle was implemented in 2009 without changing the preoperative 8-h nil per os, and in the absence of either a carbohydrate loading strategy or hyperglycemic management protocol. Hyperglycemia was defined as blood glucose level > 140 mg/dL. The primary endpoint was SSI defined by the Centers for Disease Control National Nosocomial Infections Surveillance. RESULTS: Of 690 patients included, 112 (16.2%) had pre-existing DM. Overall SSI rates were significantly higher in DM patients as compared to non-DM patients (28.7 vs. 22.3%, p = 0.042). Postoperative hyperglycemia was more frequently seen in non-DM patients (46 vs. 42.9%). The SSI bundle reduced SSI rates (17 vs. 29.3%, p < 0.001), but the rate of hyperglycemia remained unchanged for DM or non-DM patients (pre-bundle 59%; post-bundle 62%, p = 0.527). Organ/space SSI rates were higher in patients with pre- and postoperative hyperglycemia (12.6%) (p = 0.017). Overall SSI rates were higher in DM patients with hyperglycemia as compared to non-DM patients with hyperglycemia (35.6 vs. 20.8%, p = 0.002). At multivariate analysis DM, chronic steroid use, chemotherapy and SSI bundle were predictive factors for SSI. CONCLUSIONS: This study showed that non-DM patients have a postoperative hyperglycemia rate as high as 46% in spite of the SSI bundle. A positive correlation was found between stress hyperglycemia and organ/space SSI rates regardless of the DM status. These data support the need for a strategy to prevent stress hyperglycemia in non-DM patients undergoing colorectal resections.

Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial.

AIM: A randomized controlled trial was conducted to test the null hypothesis that there is no difference in circumferential resection margin (CRM) between extralevator abdominoperineal excision (ELAPE) and non-ELAPE for rectal cancer. METHOD: This was a multicentre, randomized controlled trial registered as NCT01702116. Patients with rectal cancer involving the external anal sphincter were randomized to ELAPE or non-ELAPE following neoadjuvant chemoradiation. Randomization was performed according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. The primary end-point was CRM (in mm), defined as the shortest distance between the tumour and the cut edge of the specimen. Pathologists and centralized pathology were blinded to the patients' study arm. Interrater reliability (IRR) was assessed using Kendall's coefficient. Intra-operative perforation (IOP) was any rectal defect determined at pathology. Complications were classified using the Clavien-Dindo classification. Participating surgeons were retrained and credentialed. A sample size calculation showed that 34 subjects would provide sufficient power to reject the null hypothesis. RESULTS: Thirty-four patients underwent the allocated intervention. Seventeen patients treated with ELAPE were comparable with 17 patients treated with non-ELAPE regarding age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) class and pre-existing comorbidities. CRM depth (7.14 ± 5.76 mm vs 2.98 ± 3.28 mm, P = 0.016) and involvement rates (5.8% vs 41.0%, P = 0.04) were significantly increased in patients treated with ELAPE. The IRR for CRM was 0.78. There were no significant differences in IOP (5.8% vs 11.7%, P = 0.77) and complication rates (29% vs 29%, P = 0.97). CONCLUSIONS: ELAPE was associated with statistically improved CRM with no difference in IOP and complication rates compared with non-ELAPE for rectal cancer involving the external anal sphincter.

Efficacy and safety of cannabinoid oromucosal spray for multiple sclerosis spasticity.

BACKGROUND: The approval of 9-δ-tetrahydocannabinol and cannabidiol (THC:CBD) oromucosal spray (Sativex) for the management of treatment-resistant multiple sclerosis (MS) spasticity opened a new opportunity for many patients. The aim of our study was to describe Sativex effectiveness and adverse events profile in a large population of Italian patients with MS in the daily practice setting. METHODS: We collected data of all patients starting Sativex between January 2014 and February 2015 from the mandatory Italian medicines agency (AIFA) e-registry. Spasticity assessment by the 0-10 numerical rating scale (NRS) scale is available at baseline, after 1 month of treatment (trial period), and at 3 and 6 months. RESULTS: A total of 1615 patients were recruited from 30 MS centres across Italy. After one treatment month (trial period), we found 70.5% of patients reaching a ≥20% improvement (initial response, IR) and 28.2% who had already reached a ≥30% improvement (clinically relevant response, CRR), with a mean NRS score reduction of 22.6% (from 7.5 to 5.8). After a multivariate analysis, we found an increased probability to reach IR at the first month among patients with primary and secondary progressive MS, (n=1169, OR 1.4 95% CI 1.04 to 1.9, p=0.025) and among patients with >8 NRS score at baseline (OR 1.8 95% CI 1.3-2.4 p<0.001). During the 6 months observation period, 631(39.5%) patients discontinued treatment. The main reasons for discontinuation were lack of effectiveness (n=375, 26.2%) and/or adverse events (n=268, 18.7%). CONCLUSIONS: Sativex can be a useful and safe option for patients with MS with moderate to severe spasticity resistant to common antispastic drugs.

Recurrence of rectal prolapse following rectopexy: a pooled analysis of 532 patients.

AIM: The study was designed to address the unanswered question of the influence of the extent of rectal mobilization, the type of rectal fixation and the surgical access (open vs laparoscopic) on recurrence rates following abdominal surgery for full-thickness rectal prolapse (FTRP). METHOD: Individual patient data were pooled and data merging was performed following comparison of variable definitions to ensure similarity in definitions. Recurrence after rectopexy was defined as the presence of FTRP on physical examination. The impact of categorical factors on recurrence was assessed using Fisher's exact and the chi-squared tests. Recurrence-free survival curves were generated for patients and differences in time to recurrence were compared using the log rank test. Factors passing univariate screening with a P value < 0.1 were included in a multivariate model. RESULTS: After data matching and merging, 532 patients were included. The duration of follow-up ranged from 12 to 235 months. There were 46 (8.6%) recurrences at a median follow-up of 60 months. Mean age was 53.6 ± 17 years, 359 (67.5%) were female, the mean length of external prolapse was 6.3 ± 4 cm, and previous abdominal surgery had taken place in 33.7%. Four variables were identified on initial univariate screening as being related to recurrence. They included a history of incontinence (P = 0.09), constipation (P = 0.018), the extent of rectal mobilization (P = 0.004) and the role of sigmoid resection (P = 0.057). Using multivariate analysis, only the degree of mobilization was independently associated with recurrence (P = 0.026). CONCLUSION: Circumferential rectal mobilization during rectopexy was associated with a decreased long-term recurrence rate. The type of rectal fixation and the type of surgical access did not influence recurrence.

Impact of a surgical site infection reduction strategy after colorectal resection.

AIM: This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal resection. METHOD: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2006-14 were utilized and supplemented by institutional review board-approved chart review. The primary end-point was superficial and deep incisional SSI. The inclusion criterion was colorectal resection. The SSI reduction strategy consisted of preoperative (blood glucose, bowel preparation, shower, hair removal), intra-operative (prophylactic antibiotics, antimicrobial incisional drape, wound protector, wound closure technique) and postoperative (wound dressing technique) components. The SSI reduction strategy was prospectively implemented and compared with historical controls (pre-SSI strategy arm). Statistical analysis included Pearson's chi-square test, and Student's t-test performed with spss software. RESULTS: Of 1018 patients, 379 were in the pre-SSI strategy arm, 311 in the SSI strategy arm and 328 were included to test durability. The study arms were comparable for all measured parameters. Preoperative wound class, operation time, resection type and stoma creation did not differ significantly. The SSI strategy arm demonstrated a significant decrease in overall SSI rates (32.19% vs 18.97%) and superficial SSI rates (23.48% vs 8.04%). Deep SSI and organ space rates did not differ. A review of patients testing durability demonstrated continued improvement in overall SSI rates (8.23%). CONCLUSION: The implementation of an SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resection over its initial 3 years, and its durability as demonstrated by continuing improvement was seen over an additional 2 years.

Laparoscopic right colectomy vs laparoscopic-assisted colonoscopic polypectomy for endoscopically unresectable polyps: a randomized controlled trial.

AIM: A randomized controlled trial (RCT) was conducted to test the null hypothesis that there is no difference in complication rates and length of stay (LOS) between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps of the right colon. METHOD: A single-centre RCT (NCT01986699) was conducted on patients with polyps of the right colon deemed by the gastroenterologist to be unresectable. Patients underwent a repeat colonoscopy with biopsy by an interventional endoscopist and were allocated to LRC or LACP. Patients with a nonlift sign, dysplasia, adenocarcinoma, inflammatory bowel disease or familial adenomatous polyposis were excluded from the trial. The study was powered to detect a 73% difference in the LOS which required 17 patients in each arm with an α error of 0.05 and a power of 95%. RESULTS: Thirty-four patients were comparable for age (P = 0.919), gender (P = 0.364), body mass index (P = 0.634), American Society of Anesthesiologists class (P = 0.388) and previous abdominal surgery (P = 0.366). There was no significant difference in the preoperative morphology (P = 0.485), location (P = 0.297), size (P = 0.690) or histology of the polyps (P = 0.779). LRC patients experienced a longer operating time (180 vs 90 min; P = 0.001), required more intravenous infusion (3.1 vs 2.0 l; P = 0.025), took significantly longer to pass flatus (2.88 vs 1.44 days; P < 0.001), resumed solid food later (3.94 vs 1.69 days; P < 0.001) and had a longer postoperative LOS (4.94 vs 2.63 days; P < 0.001). Postoperative complications (P = 0.656), readmissions (P = 0.5) and reoperations (P = 0.5) did not differ. Final size (P = 0.339) and histology (P = 0.104) of the polyps did not differ. There were four cancers in the LRC arm. At follow-up colonoscopy with biopsy of the scar in 10 patients at 15.3 months, one patient had recurrence of the polyp at the site of the previous LACP. CONCLUSION: LACP and LRC had similar complication rates, but LOS was shorter after LACP.

Diagnostic tools for assessment of urinary dysfunction in MS patients without urinary disturbances.

Many guidelines are available for the management of lower urinary tract symptoms (LUTSs) in multiple sclerosis (MS) patients, but no agreement exists on the best approach for subjects without LUTSs. The objective of this study was to evaluate whether LUTSs can be detected in MS patients asymptomatic for urinary dysfunction, comparing three different tools [measure of post-void residual volume (PRV), bladder diary (BD), a focused questionnaire (IPSS)], and whether disability, disease duration and signs of pyramidal involvement are linked to their subclinical presence. 178 MS patients (118 women) have been included (mean age 41.2 years, mean disease duration 11.3 years, mean EDSS 2.2), and tested with the above-mentioned tools. PRV was abnormal in 14 subjects (7.8%), associated to abnormal findings at IPSS in 3 cases, at BD in 2 cases, at both in 1. BD was abnormal in 37 subjects (20.8%), with concomitant abnormal PRV in 2, abnormal IPSS in 10 cases, abnormal IPSS and BD in 1. IPSS was ≥ 9 in 43 subjects (24.1%). At least one test was abnormal in 76 patients (42.7%): 1 in 57 patients (32.0%), 2 in 17 (9.5%), and 3 tests in 2 (1.1%). Patients with at least one abnormal urinary variable, compared to patients without urinary abnormalities, had a more frequent pyramidal involvement (69.5 vs. 16.8%, χ(2) = 48.6, p < 0.00001), a more frequent occurrence of EDSS ≥2 (83.1 vs. 23.5%, χ(2) = 56.9, p < 0.00001), and a longer disease duration (15.7 ± 7.3 vs. 9.1 ± 7.1, t = 5.7, p < 0.00001). Asymptomatic LUTS were frequent but none of the tests used permitted to better identify asymptomatic patients.

Juvenile dermatomyositis: A report of three cases.

Juvenile dermatomyositis (JDM), an autoimmune idiopathic myositis, is characterized by rash and proximal muscle weakness. Immunohistopathology typically shows perivascular inflammatory infiltrate with predominance of CD4+ T lymphocytes, perifascicular atrophy, and upregulation of major histocompatibility complex class I. JDM has been attributed to a humoral-driven muscle microangiopathy probably implicating the type I interferon pathway. Tubulo-reticular inclusions present in endothelial cell of muscle are biomarkers of interferon exposure, and so may be an indirect data of this myopathy especially in the absence of rash and inflammatory infiltrate. We report on three patients in which electron microscopy solves the differential diagnosis among infantile myositis showing peculiar inclusions.