ABSTRACT
AIMS: The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST. METHODS: This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction. RESULTS: Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences. CONCLUSIONS: These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.
Subject(s)
Bile Duct Diseases , Cholecystectomy, Laparoscopic , Surgeons , Humans , Cholecystectomy, Laparoscopic/methods , Prospective Studies , Cholangiography/methods , Coloring AgentsABSTRACT
BACKGROUND: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses. METHODS: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed. RESULTS: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23). CONCLUSIONS: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.
Subject(s)
Anti-Bacterial Agents , Drainage , Tomography, X-Ray Computed , Treatment Failure , Humans , Male , Female , Case-Control Studies , Middle Aged , Drainage/methods , Risk Factors , Aged , Anti-Bacterial Agents/therapeutic use , Diverticulitis, Colonic/therapy , Diverticulitis, Colonic/diagnostic imaging , Diverticulitis, Colonic/surgery , Abdominal Abscess/therapy , Abdominal Abscess/etiology , Abdominal Abscess/diagnostic imaging , Abdominal Abscess/surgery , Acute Disease , Adult , Abscess/therapy , Abscess/diagnostic imaging , Abscess/surgery , Conservative Treatment/methodsABSTRACT
BACKGROUND: We conducted a systematic review and meta-analysis to evaluate the role of High Energy Devices (HEDs) versus conventional clamp and tie technique in thyroidectomy. This work is endorsed by the Italian Society of Surgical Endoscopy (Italian Society of Endoscopic Surgery and new technologies-SICE) in the broader project on the evaluation of the role of HEDs in different surgical settings with the full health technology assessment report. MEHODS: Inclusion criteria were adult patients (≥ 18 years old) undergoing Thyroidectomy/Parathyroidectomy conducted with High Energy Devices (as ultrasonic (US), radiofrequency (RF), and hybrid energy (H-US/RF)) in the setting of thyroid surgery (both partial and total) for benign and malign diseases. However, some variability was found in included studies and described in the text. This systematic review and meta-analysis were performed according to the Cochrane handbook for systematic reviews, and the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines were pursuit. Selection of abstracts was performed in Ryyan system by 2 independent reviewers, and doubts were solved by another independent reviewer. At the end of literature research, Randomized controlled trials and observational studies were included. Risk of Bias was assessed with ROB2 for RCTs, and New Castle Ottawa Scale for Observational studies. RESULTS: The literature search yielded 47 studies, including 29 RCTs and 18 observational studies. Meta-analysis was performed for 29 randomized clinical trials. Outcomes included in the comparison between High Energy Devise and conventional technique groups were operative time, operative blood loss, overall post-operative drainage volume, length of stay, complications, and costs. HED significantly reduced operative time (28 studies, 3097patients; MD -128.8; 95% CI -34.4 to -23.20; I2 = 96%, p < 0.00001, Random-effect), intra-operative blood loss (13 studies, 642 vs 519 patients; SMD -0.82; 95% CI -1.33 to -0.32; I2 = 93%, p < 0.00001, Random-effect), LOS (22 studies, 2808 vs 2789 patients; MD -0.38, 95% CI -0.59 to -0.17; I2 = 98%, p < 0.00001 Random-effect), and healthcare costs (8 studies, 1138 vs 1129 patients, SMD 1.05; 95% CI -0.06 to 2.16; I2 = 99%, p < 0.00001 Random-effect). The rate of overall intraoperative complications was significantly different between both groups (25 studies, 2804 vs 2775 patients; RR 0.88, 95% CI 0.80 to 0.97; I2 = 38%, p = 0.03 Random-effect), but the sensitivity analysis did not find a statistically significant difference (6 studies, 605 vs 594 patients, RR; 95% CI to; I2 = 0%, p = 0.50, Random-effect). There was no difference in the subgroup analysis for the occurrence of transient and permanent RLN palsy, nor hematoma formation and hypocalcaemia. DISCUSSION: Though findings of our systematic review and metanalysis are limited by heterogeneous data, surgeons, hospital managers, and policymakers should note that the use of High Energy Devices compared to conventional clamp and tie technique have reduced operative times, intra-operative blood loss, length of stay, and hospital costs in patients underwent to tyroid surgery. Future work must explore issues of equity to mitigate barriers to patient access to safe thyroid surgical care and define better this initial results.
Subject(s)
Thyroidectomy , Humans , Thyroidectomy/methods , Thyroidectomy/adverse effects , Thyroidectomy/instrumentation , Thyroid Diseases/surgery , Parathyroidectomy/methodsABSTRACT
INTRODUCTION: According to the literature, there is no clear definition of a High Energy Devices (HEDs), and their proper indications for use are also unclear. Nevertheless, the flourishing market of HEDs could make their choice in daily clinical practice arduous, possibly increasing the risk of improper use for a lack of specific training. At the same time, the diffusion of HEDs impacts the economic asset of the healthcare systems. This study aims to assess the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: On behalf of the Italian Society of Endoscopic Surgery and New Technologies, experts performed a systematic review and meta-analysis and synthesised the evidence assessing the efficacy and safety of HEDs compared to electrocautery devices while performing laparoscopic cholecystectomy (LC). Only randomised controlled trials (RCTs) and comparative observational studies were included. Outcomes were: operating time, bleeding, intra-operative and post-operative complications, length of hospital stay, costs, and exposition to surgical smoke. The review was registered on PROSPERO (CRD42021250447). RESULTS: Twenty-six studies were included: 21 RCTs, one prospective parallel arm comparative non-RCT, and one retrospective cohort study, while three were prospective comparative studies. Most of the studies included laparoscopic cholecystectomy performed in an elective setting. All the studies but three analysed the outcomes deriving from the utilisation of US sources of energy compared to electrocautery. Operative time was significantly shorter in the HED group compared to the electrocautery group (15 studies, 1938 patients; SMD - 1.33; 95% CI - 1.89 to 0.78; I2 = 97%, Random-effect). No other statistically significant differences were found in the other examined variables. CONCLUSIONS: HEDs seem to have a superiority over Electrocautery while performing LC in terms of operative time, while no difference was observed in terms of length of hospitalisation and blood loss. No concerns about safety were raised.
Subject(s)
Cholecystectomy, Laparoscopic , Laparoscopy , Humans , Hospitalization , Length of Stay , Postoperative Complications , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices. METHODS: A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings. RESULTS: The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged. CONCLUSIONS: The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.
Subject(s)
Hospitals , Technology Assessment, Biomedical , Humans , Technology Assessment, Biomedical/methods , Italy , Pancreatectomy , Cost-Benefit AnalysisABSTRACT
PURPOSE: Adrenocortical carcinoma (A.C.C.) is a rare tumour, often discovered at an advanced stage and associated with a poor prognosis. Surgery is the treatment of choice. We aimed to review the different surgical approaches trying to compare their outcome. METHODS: This comprehensive review has been carried out according to the PRISMA statement. The literature search was performed in PubMed, Scopus, the Cochrane Library and Google Scholar. RESULTS: Among all studies identified, 18 were selected for the review. A total of 14,600 patients were included in the studies, of whom 4421 were treated by mini-invasive surgery (M.I.S.). Ten studies reported 531 conversions from M.I.S. to an open approach (OA) (12%). Differences were reported for operative times as well as for postoperative complications more often in favour of OA, whereas differences for hospitalization time in favour of M.I.S. Some studies showed an R0 resection rate from 77 to 89% for A.C.C. treated by OA and 67 to 85% for tumours treated by M.I.S. The overall recurrence rate ranged from 24 to 29% for A.C.C. treated by OA and from 26 to 36% for tumours treated by M.I.S. CONCLUSIONS: OA should still be considered the standard surgical management of A.C.C. Laparoscopic adrenalectomy has shown shorter hospital stays and faster recovery compared to open surgery. However, the laparoscopic approach resulted in the worst recurrence rate, time to recurrence and cancer-specific mortality in stages I-III ACC. The robotic approach had similar complications rate and hospital stays, but there are still scarce results about oncologic follow-up.
Subject(s)
Adrenal Cortex Neoplasms , Adrenocortical Carcinoma , Humans , Adrenocortical Carcinoma/surgery , Adrenalectomy , Hospitalization , Length of Stay , Adrenal Cortex Neoplasms/surgeryABSTRACT
BACKGROUND: Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached. METHODS: The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications' occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item. RESULTS: 1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery. CONCLUSIONS: Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.
Subject(s)
Colorectal Neoplasms , Colorectal Surgery , Laparoscopy , Colorectal Neoplasms/surgery , Humans , Length of Stay , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Prospective StudiesABSTRACT
INTRODUCTION: It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor. Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy. MATERIALS AND METHODS: This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions. RESULTS: This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome). CONCLUSIONS: This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence.
Subject(s)
Cholecystectomy, Laparoscopic , Pneumoperitoneum , Cholecystectomy, Laparoscopic/adverse effects , Cholecystectomy, Laparoscopic/methods , Humans , Pain, Postoperative/etiology , Pneumoperitoneum/etiology , Pneumoperitoneum, Artificial/methods , Randomized Controlled Trials as TopicABSTRACT
INTRODUCTION: Indocyanine green (ICG) fluorescence is an emerging technique in the surgical field. Among its various applications, it allows surgeons to have real-time visualization of the lymphatic drainage of an organ. The primary outcome of our study is the feasibility and safety of ICG-guided colorectal surgery. Our secondary outcome is the efficacy of ICG-guided lymphadenectomy and whether or not ICG positivity correlates with the identification of nodal metastasis. MATERIAL AND METHODS: We conducted a single-center prospective study including 32 patients who underwent surgery for colorectal cancer. For each case, ICG was injected into the tumor area either prior to or during surgery. Tumor specimens and excised lymph nodes were analyzed using hematoxylin and eosin (H&E) staining. RESULTS: In all patients, ICG injected in the tumor area allowed clear visualization of the lymphatic drainage. A total of 499 lymph nodes were collected, with a mean of 16 per patient. Fifty ICG positive lymph nodes outside the standard lymphadenectomy zone were examined; however, none of the nodes showed signs of nodal metastasis. CONCLUSIONS: ICG-guided colorectal surgery is safe, feasible and easily reproducible, with a relatively low cost and no radiation exposure. ICG can help the surgeon to visualize the anatomical structures. We did not find an oncological diagnostic advantage in the use of ICG-guided nodal navigation.
Subject(s)
Colorectal Neoplasms , Lymph Node Excision , Colectomy/methods , Colorectal Neoplasms/pathology , Colorectal Neoplasms/surgery , Humans , Indocyanine Green , Lymph Node Excision/methods , Lymph Nodes/pathology , Lymph Nodes/surgery , Lymphatic Metastasis/pathology , Prospective StudiesABSTRACT
BACKGROUND: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. METHODS: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery. RESULTS: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. CONCLUSION: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon's preference, economic features, and specific drawbacks of the energy employed.
Subject(s)
Laparoscopy , Dissection , Humans , Italy , Minimally Invasive Surgical Procedures , PancreasABSTRACT
BACKGROUND: We report the results of the operative treatment for type 2 endoleak (T2E) involving the inferior mesenteric artery (IMA) using the transarterial embolization (TAE) or the video laparoscopic ligation (VLS). METHODS: Between January 2005 and December 2015, we retrospectively analyzed 901 patients treated with endovascular aortic repair (EVAR): 883 (98%) had 1 valid postoperative radiologic evaluation, at least. All patients with operative repair for IMA-related T2E entered the final analysis. Indication of their operative repair was sac enlargement (>5 mm within 6 months or >1 cm from the preoperative diameter, irrespectively of the postoperational time) and/or its persistence >12 months. RESULTS: We detected 192 (21.7%) T2Es, overall. We identified 37 (4.2%) IMA-related T2Es, and treated 21 cases (VLS n = 11, TAE n = 10). Aneurysm-related mortality and major or minor morbidity was never observed. Time of intervention did not differ significantly (minutes, VLS = 97 ± 46 vs. TAE = 95 ± 21, P = 0.901). Hospitalization was significantly lower in the TAE group (days, 4 ± 2 vs. 1 ± 0.4, P < 0.001). No patient was lost at a mean follow-up of 46 ± 32 months (range, 1-110; median, 48). At last follow-up, sac diameter was significantly more stable in the VLS (mm, 60 ± 10 vs. 55 ± 7, P = 0.593) than that in the TAE group (mm, 57 ± 9 vs. 63 ± 10, P = 0.050). The IMA-related T2E reintervention rate was not significantly different between the groups (VLS, n = 0 [0%] vs. TAE, n = 2 [20.0%], P = 0.213). Secondary aortic reintervention rate was 28.6% (n = 6), and secondary open conversion rate was 9.5% (VLS, n = 1 [9.1%] vs. TAE, n = 1 [10.0%], P = 1). CONCLUSIONS: In authors' experience, operative treatment of IMA-related T2E was safe; VLS proved to be effective and durable in sealing this type of T2E. Patients receiving correction of IMA-related T2E after EVAR remained at risk for development of any type of endoleaks, as well as at risk of reintervention.
Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Embolization, Therapeutic , Endoleak/therapy , Endovascular Procedures/adverse effects , Laparoscopy/methods , Mesenteric Artery, Inferior/surgery , Video-Assisted Surgery/methods , Aged , Aged, 80 and over , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortography , Databases, Factual , Embolization, Therapeutic/adverse effects , Endoleak/diagnostic imaging , Endoleak/etiology , Endoleak/surgery , Female , Humans , Italy , Laparoscopy/adverse effects , Length of Stay , Ligation , Male , Mesenteric Artery, Inferior/diagnostic imaging , Middle Aged , Reoperation , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Video-Assisted Surgery/adverse effectsABSTRACT
Purpose: Diastasis of rectus abdominis (DRA) refers to a separation of the rectus abdominis from the linea alba, which is common in the female population during pregnancy and in the postpartum period. The present study aimed at investigating DRA severity, risk factors and associated disorders. Methods: In the present cross-sectional study, a web-based questionnaire was addressed to the 23,000 members of the Women's Diastasis Association. The questionnaire comprised three parts, dedicated respectively to diastasis characteristics, possible risk factors, and related disorders. Faecal and urinary incontinences were assessed using the Wexner and ICIQ-SF score, respectively. Risk factors for diastasis severity (<3, 3-5, >5â cm) were evaluated by a multinomial regression model. Results: Four thousand six hundred twenty-nine women with a mean age (SD) of 39.8 (6.5) years and a median BMI of 23.7â kg/m2 (range 16.0-40.0) responded to the questionnaire. Proportion of DRA >5â cm increased from 22.8% in norm weight women to 44.0% in severely obese women, and from 10.0% in nulliparous women to 39.3% in women with >3 pregnancies. These associations were confirmed in multivariable analysis. DRA severity was associated with the risk of abdominal hernia and pelvic prolapse, whose prevalence more than doubled from women with DRA <3â cm (31.6% and 9.7%, respectively) to women with DRA >5â cm (68.2% and 20.2%). In addition, most patients reported postural pain and urinary incontinence, whose frequency increased with DRA severity. Conclusion: The present study confirmed that DRA severity increases with increasing BMI and number of pregnancies. Larger separation between rectal muscles was associated with increased risk of pain/discomfort, urinary incontinence, abdominal hernia and pelvic prolapse. Prospective studies are needed to better evaluate risk factors.
ABSTRACT
BACKGROUND: Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes. METHODS: CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC. RESULTS: The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies. CONCLUSIONS: The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.
Subject(s)
Colonic Neoplasms , Intestinal Obstruction , Humans , Prospective Studies , Quality of Life , Intestinal Obstruction/etiology , Intestinal Obstruction/surgery , Colonic Neoplasms/complications , Colonic Neoplasms/surgery , Stents/adverse effects , Observational Studies as TopicABSTRACT
PURPOSE: Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. METHODS: Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. RESULTS: In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". CONCLUSIONS: Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management.
Subject(s)
Diverticulitis , Laparoscopy , Peritonitis , Humans , Evidence-Based Medicine , Diverticulitis/surgery , Anastomosis, Surgical , Critical Care , Peritonitis/surgeryABSTRACT
Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.
Subject(s)
Hernia, Inguinal , Laparoscopy , Humans , Retrospective Studies , Herniorrhaphy/methods , Groin/surgery , Laparoscopy/methods , Hernia, Inguinal/surgery , Italy , Surgical Mesh , Treatment OutcomeABSTRACT
Minimally invasive surgery (MIS) is a widespread approach in general surgery. Computer guiding software, such as the augmented reality (AR), the virtual reality (VR) and mixed reality (MR), has been proposed to help surgeons during MIS. This study aims to report these technologies' current knowledge and diffusion during surgical training in Italy. A web-based survey was developed under the aegis of the Italian Society of Endoscopic Surgery (SICE). Two hundred and seventeen medical doctors' answers were analyzed. Participants were surgeons (138, 63.6%) and residents in surgery (79, 36.4%). The mean knowledge of the role of the VR, AR and MR in surgery was 4.9 ± 2.4 (range 1-10). Most of the participants (122, 56.2%) did not have experience with any proposed technologies. However, although the lack of experience in this field, the answers about the functioning of the technologies were correct in most cases. Most of the participants answered that VR, AR and MR should be used more frequently for the teaching and training and during the clinical activity (170, 80.3%) and that such technologies would make a significant contribution, especially in training (183, 84.3%) and didactic (156, 71.9%). Finally, the main limitations to the diffusion of these technologies were the insufficient knowledge (182, 83.9%) and costs (175, 80.6%). Based on the present study, in Italy, the knowledge and dissemination of these technologies are still limited. Further studies are required to establish the usefulness of AR, VR and MR in surgical training.
Subject(s)
Augmented Reality , Virtual Reality , Humans , User-Computer Interface , Minimally Invasive Surgical Procedures/education , ItalyABSTRACT
Since 2010, several guidelines and consensus papers have been proposed to support surgeons in the decision-making process (Cuccurullo et al. in Hernia 17(5):557-566, 2013; Silecchia et al. in Surg Endosc 29:2463-2484, 2015; Bittner et al. in Surg Endosc 33(11):3511-3549, 2015) with the conclusion that laparoscopic repair (LR) has gained popularity in the treatment of IH.To date, however, it is not yet clear as to the uptake of LR for IH on national basis. Only dated studies encompassing of all types of incisional hernia repairs are available in literature (Bisgaard et al. in Br J Surg 96:1452-1457, 2009). The aim of our study is to present a snapshot of Italian data for LR of ventral hernias, over a 6 years period, including volume of LR, procedural features and major postoperative outcomes. Data were extracted from the Italian Hospital Information System (HIS) that collects clinical and administrative information regarding each hospital admission of every patient discharged from any hospital in Italy. Using Hospital Discharge records regional Databases (HDD), all laparoscopic ventral hernia procedures carried out in public and private hospitals between 2015 and 2020, in patients over 18 years and resident in Italy, were collected based on diagnosis and procedure codes. The National Agency for Regional Health Services (AgeNaS) oversees the management and analysis of data. All hospital admissions that occurred between 2015 and 2020 were analyzed.A total of 154,546 incisional hernia repairs were performed in Italy from 2015 to 2020. Of these, 20,789 (13.45%) were minimally invasive repairs. The number of procedures performed increased significantly over time, constituting 11.96 and 15.24% of all procedures performed in 2015 and 2020 respectively. However, considering the whole period, the mean annual change was-5.58% (CI - 28.6% to 17.44%; p < 0.0001).Urgent minimally invasive repairs were performed in 1968 cases (1.27%). The absolute rate of laparoscopically treated patients needing an urgent surgical procedure increased overtime (from 7.36% in 2015 to 13.418% in 2020). The mean annual change registered over the whole period was 7.42%. 92% (CI - 0.03 to 14.09%; p < 0.0001). However, when considering the period from 2015 to 2019, the mean annual change was 10.42% (CI 6.35 to 14.49%; p < 0.0001). To our knowledge this is the first nationwide Italian report presenting the national workload of surgical units and the main perioperative features of minimally invasive surgery for ventral hernia repairs.