Open versus laparoscopic gastrectomy for advanced gastric cancer: a propensity score matching analysis of survival in a western population-on behalf of the Italian Research Group for Gastric Cancer.

BACKGROUND: Oncologic outcomes after laparoscopic gastrectomy for advanced gastric cancer in the West have been poorly investigated. The aim of the present study was to compare survival outcomes in patients undergoing curative-intent laparoscopic and open gastrectomy for advanced gastric cancer in several centres belonging to the Italian Research Group for Gastric Cancer. METHODS: Data of patients operated between 2015 and 2018 were retrospectively analysed. Propensity Score Matching was performed to balance baseline characteristics of patients undergoing laparoscopic and open gastrectomy. The primary endpoint was 3-year overall survival. Secondary endpoints were 3-year disease-free survival and short-term outcomes. Multivariable regression analyses for survival were conducted. RESULTS: Data were retrieved from 20 centres. Of the 717 patients included, 438 patients were correctly matched, 219 per group. The 3-year overall survival was 73.6% and 68.7% in the laparoscopic and open group, respectively (p = 0.40). When compared with open gastrectomy, laparoscopic gastrectomy showed comparable 3-year disease-free survival (62.8%, vs 58.9%, p = 0.40), higher rate of return to intended oncologic treatment (56.9% vs 40.2%, p = 0.001), similar 30-day morbidity/mortality. Prognostic factors for survival were ASA Score ≥ 3, age-adjusted Charlson Comorbidity Index ≥ 5, lymph node ratio ≥ 0.15, p/ypTNM Stage III and return to intended oncologic treatment. CONCLUSIONS: Laparoscopic gastrectomy for advanced gastric cancer offers similar rates of survival when compared to open gastrectomy, with higher rates of return to intended oncologic treatment. ASA score, age-adjusted Charlson Comorbidity Index, lymph node ratio, return to intended oncologic treatment and p/ypTNM Stage, but not surgical approach, are prognostic factors for survival.

Laparoscopic transperitoneal hernia repair (TAPP) in emergency: long-term follow-up in a high volume centre.

PURPOSE: Aim of this study was to analyse feasibility, safety and effectiveness of laparoscopic transperitoneal hernia repair (TAPP) approach to inguinal hernias in the emergency setting, with a longer follow-up than the studies present in literature. METHODS: We retrospectively analysed all patients who underwent emergency TAPP hernia repair in San Marco Hospital (Zingonia, Italy), from September 2010 to June 2020. A prospectively collected database of 685 consecutive TAPP hernia repair was reviewed. Feasibility and safety were evaluated through operative time, conversion rate, perioperative mortality, morbidity and prosthesis infection rate. Effectiveness was assessed by recurrence and complication rate, acute (during admission) and chronic (during follow-up) pain by Visual Analogic Scale (VAS), and recovery to normal activity in a long-term follow-up (mean period 1718 days). RESULTS: The final study group included 47 patients. The mean age was 59.6 years (range 22-89), 29 patients were male and 18 were female. The mean operation time was 64 min. Two cases were converted to open approach (4%). In four cases bowel resection became necessary (8.5%). Appendicectomy and omentectomy occurred once and twice, respectively (2% and 4%), and orchiectomy was required in two patients (4%). Seroma was the only postoperative complication that we registered in four patients. During a mean follow-up period of 1718 days, there was no recurrence of the hernia or other complications. Five patients referred mild occasional groin pain (VAS < 3), with quick relief without taking any pain killers. CONCLUSION: TAPP approach is a safe, feasible and effective therapeutic option for groin hernias in emergency setting. No recurrence or severe complications were reported in over 4 years of follow-up.

Laparoscopic pancreaticoduodenectomy for tumors of the head of pancreas; 10 cases for a single center experience.

OBJECTIVE: The tumors of the head of the pancreas are one of the leading causes of cancer-related death in Western countries. The current gold standard for these tumors is a Whipple procedure. This procedure did not change in its surgical steps since when it was initially introduced in 1935. More recently, a laparoscopic approach with similar outcomes has been described. The aim of this paper is to describe the laparoscopic surgical technique performed in our unit, reporting single center postoperative outcomes. PATIENTS AND METHODS: From the 1st January 2013 to the 31st December 2015 a database was created. Data about patients who underwent a laparoscopic pancreaticoduodenectomy (LPD) were collected prospectively. All patients were preoperatively assessed with blood samples, tumor markers, CT chest abdomen and pelvis and/or MRI pancreas. Only patients with specific characteristics were considered eligible for an LPD: performance status 0, body mass index (BMI) less than 30 kg/m2, a small neoplastic lesion (< 3.5 cm) confined to the pancreas, the absence of infiltrated organs and/or blood vessels (T1 or T2). Postoperative data and complications were recorded and described according to the Clavien-Dindo classification and the international study group of pancreatic surgery definitions. RESULTS: In a time interval of 36 months, 31 patients with an initially considered resectable pancreatic cancer were referred. 11 patients were found to have metastasis during the preoperative workout. Only 10 patients were considered eligible for a LPD. Six of them were men (60%). The mean BMI was 25.01 kg/m2 (19.6-29.8). 5 patients, who underwent to LPD did not have any comorbidities. An overall 50% of all patients were jaundice at the time of diagnosis with a mean bilirubin level of 181.3 µmol/L (119.7-307.8). All patients with a direct bilirubin greater than 250 µmol/L underwent a preoperative percutaneous biliary drainage. In the majority of the LPD performed (50%), the histology reported a pancreatic adenocarcinoma. Other postoperative histology described were: IPMN (20%), ampullar neoplasia (20%) and neuroendocrine tumor (10%). Neo-adjuvant chemotherapy was never considered indicated. The reported postoperative complications were: 1 anastomotic bleeding, 2 pancreatic fistula, 1 infected intra-abdominal collection and 1 delay gastric emptying. The pancreatic fistulas were considered grade A and grade B. One fatality after LPD occurred because of an uncontrollable, diffuse severe hemorrhagic gastritis associated with a GJ anastomosis bleeding in the POD 25. The mean hospital stay was 12.3 days (8-25). The mean operative time was 224 min (170-310). There were no intraoperative complications. The main intraoperative blood loss was 220 ml (180-400) and intraoperative blood transfusions were not required. The resection margins were negative (R0) in 100% of cases and the mean lymph nodes harvested were 24 (18-40). The LPD is still a not common practice. Our results are comparable with those reported in literature about the open technique. These remarkable surgical outcomes are probably related to the extremely careful preoperative patient selection performed. The indication for a laparoscopic vs. an open pancreaticoduodenectomy was based on a CT scan pancreas performed less than 30 days before the planned date of surgery and a careful preoperative assessment. A low complication rate and a relative short stay in hospital were associated to a good quality of life in the early postoperative period and an early referral for postoperative chemotherapy. Good clinical outcomes were associated with outstanding oncological results. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy is a feasible surgical procedure. Remarkable oncological and surgical outcomes can be achieved with a morbidity and mortality rate in line with the data reported by the large series of open procedures.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines

BACKGROUND: The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues. METHODS: The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group. RESULTS AND CONCLUSIONS: The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.(AU)

Explosive synchronization in weighted complex networks.

The emergence of dynamical abrupt transitions in the macroscopic state of a system is currently a subject of the utmost interest. Given a set of phase oscillators networking with a generic wiring of connections and displaying a generic frequency distribution, we show how combining dynamical local information on frequency mismatches and global information on the graph topology suggests a judicious and yet practical weighting procedure which is able to induce and enhance explosive, irreversible, transitions to synchronization. We report extensive numerical and analytical evidence of the validity and scalability of such a procedure for different initial frequency distributions, for both homogeneous and heterogeneous networks, as well as for both linear and nonlinear weighting functions. We furthermore report on the possibility of parametrically controlling the width and extent of the hysteretic region of coexistence of the unsynchronized and synchronized states.

Small bowel obstruction caused by mesh migration. Case report.

INTRODUCTION: Endoscopic hernia repair methods have become increasingly popular over the past 15 years. Nonetheless, there is no consensus regarding an optimal fixation method. Transabdominal sutures and titanium tacks or staples are the most traditional ones. CASE REPORT: We present a case of mechanic small bowel obstruction due to mesh migration occurring one year and a half after incisional hernia repair with polytetrafluoroethylene mesh fixed by spiral tacks. DISCUSSION: Titanium spiral tacks are dangerous because of their sharp components, which can damage organs such as the small intestine, by causing microperforations. The type of prosthesis used has also contributed to the intraluminal migration, since polytetrafluoroethylene mesh is very flexible and poorly integrates in the abdominal wall. CONCLUSION: A prosthesis of a different material combined with a different fixation system such as absorbable tacks, biological glue, or mechanical tacks without sharp components, would have obviated mesh migration.

Emergency laparoscopic treatment of acute incarcerated incisional hernia.

BACKGROUND: The emergency treatment of incisional hernias can be accomplished by a laparoscopic approach in order to avoid the common complications following open techniques. METHODS: From January 2001 to September 2007, we performed 48 emergency laparoscopic treatments of incarcerated hernias. RESULTS: In our hospital, 320 patients with incisional hernia and 65 patients with primary abdominal wall hernia were treated laparoscopically. Forty-eight patients (30 females and 18 males) underwent emergency surgery. The mean operative time was 62 min (range 45­80 min). The average length of hospital stay was 4 days (range 3­6 days). We had eight post-surgical seromas, all of which were treated successfully by needle aspiration. We saw no mesh sepsis and no metabolic or surgical complications. We had no recurrence nor the need for a second operation. Mortality was nil. CONCLUSIONS: The results of this series prove the feasibility of emergency laparoscopic surgery in incarcerated incisional hernias using new-generation meshes.

Use of fibrin glue (Tissucol) as a hemostatic in laparoscopic conservative treatment of spleen trauma.

BACKGROUND: This study aimed to evaluate the effect of fibrin glue in laparoscopic spleen-preserving procedures for traumatic rupture. METHODS: From January 2002 to December 2005, six laparoscopic spleen-preserving procedures were performed for traumatic rupture using fibrin glue. Two of the cases had previous middle and lower abdominal surgery. Survey of the abdominal cavity was performed by inserting two 5- to 12-mm trocars, one 5-mm trocar, and a 30 degree scope. A complete survey of all the patients was performed. RESULTS: None of the patients required laparotomy, and no postoperative bleeding occurred. The fibrin sealant achieved immediate hemostasis, and all the patients recovered without further splenic bleeding. The mean postoperative stay was 4.3 days (range, 4-5 days). All the patients were followed up for 3 to 12 months. Postoperative immunoglobulin scanning, ultrasonography, and computed tomography (CT) results were normal. CONCLUSIONS: Laparoscopic management of spleen trauma can be used once a positive diagnosis has been made. It is useful for assessing the degree of splenic injury. A laparoscopic spleen-preserving procedure can be used safely for patients with stable vital data. It is an effective procedure for the evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial. The topical application of a fibrin sealant in splenic trauma achieves definitive hemostasis safely, rapidly, and reliably. It also is simple to use in either laparoscopic or open procedures.

Laparoscopic versus open incisional hernia repair: an open randomized controlled study.

BACKGROUND: Incisional hernia is a common complication of abdominal surgery, and it is often a source of morbidity and high costs for health care. This is a case-control study to compare laparoscopic versus anterior-open incisional hernia repair. METHODS: 170 patients with incisional hernia were enrolled in this study between September 2001 and December 2004. Of these, 85 underwent anterior-open repair (open group: OG), and 85 underwent laparoscopic repair (laparoscopic group: LG). The clinical outcome was determined by a median follow-up of 24.0 months for LG and OG. RESULTS: No difference was noticed between the two groups in age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and incisional hernia diameter. Mean operative time was 61.0 min for LG patients and 150.9 min for OG patients (p < .05). Mean hospitalization was 2.7 days for LG patients and 9.9 days for OG patients (p < .05). Mean return to work was 13 days (range, 6-15 days) in LG patients and 25 days (range, 16-30 days) in OG patients. Complications occurred in 16.4 % of LG patients and 29.4 % of OG patients, with a relapse rate of 2.3% in LG and 1.1% in OG patients. CONCLUSIONS: Short-term results indicate that laparoscopic incisional hernia repair is associated with a shorter operative time and hospitalization, a faster return to work, and a lower incidence of wound infections and major complications compared to the anterior-open procedure. Further studies and longer follow-up are required to confirm these findings.

Use of fibrin glue (Tissucol) in laparoscopic repair of abdominal wall defects: preliminary experience.

INTRODUCTION: The aim of this study was to establish the efficacy and tolerability of human fibrin glue (Tissucol) for the nontraumatic fixation of a composite prosthesis (Parietex) in the laparoscopic repair of small to medium-sized incisional hernias and primary defects of the abdominal wall. MATERIALS AND METHODS: From October 2003 to October 2005, 40 patients underwent laparoscopic repair at the hands of one surgeon with expertise in laparoscopic surgery; all meshes were implanted in an intraperitoneal position. Follow-up visits were scheduled for 7 days and 1, 6, and 12 months. These included assessments for pain and postoperative complications. RESULTS: Forty patients (24 females, 16 males) with a mean age of 50 years (range, 26-65 years) and a mean Body Mass Index (BMI) of 27 (range 25 to 30) were included in the study. Sixteen patients had incisional hernias, and 24 had primary defects. The size of the defects varied from 2 to 7 cm. Adhesiolysis was necessary in 92.5% of cases (25/40). There were no intraoperative complications or conversions. After a mean follow-up of 16 months (range, 3-24 months), no postoperative complications were observed. The mean surgical intervention time was 36 min (range, 12-40 min), with an average hospitalization time of 1 day. CONCLUSIONS: The use of fibrin glue in the present study provided stable and uniform fixation of the prosthesis and minimized intraoperative and postoperative complications. Consequently, laparoscopic treatment of small to medium-sized abdominal defects using this approach is our therapeutic option of choice.

Fibrin glue for mesh fixation in laparoscopic transabdominal preperitoneal (TAPP) hernia repair: indications, technique, and outcomes.

BACKGROUND: The efficacy and safety of prosthesis fixation were studied by means of fibrin glue (Tissucol, Baxter Healthcare) during laparoscopic transabdominal preperitoneal (TAPP) treatment of inguinal and femoral hernias. METHODS: Between September 2001 and December 2004, fibrin glue was used for mesh fixation during TAPP. RESULTS: In this study, 320 hernias were treated for 230 patients (225 men and 5 women) with an average age of 45 years (range, 20-75 years). No perioperative complications were observed. After an average follow-up period of 26 months (range, 1-40 months), the only postoperative complications observed were six seromas (1.8%) and one trocar-site hematoma (0.3%). The mean operating time was 30 min for unilateral hernias and 50 min for bilateral hernias, whether primary or recurrent. Patients usually were discharged the day after surgery and returned to work after 5 days. CONCLUSIONS: The authors' experience demonstrates that fibrin glue (Tissucol) is an effective method for mesh fixation during TAPP.

Prospective clinical study of laparoscopic treatment of incisional and ventral hernia using a composite mesh: indications, complications and results.

The aim of this study is to establish the indications, safety, efficacy, feasibility and reproducibility of the laparoscopic technique in treating defects in the abdominal wall, including those of large dimensions, to standardise the surgical technique and to confirm the performance of the composite prosthesis used (Parietex, Sofradim). The study encompassed the period from January 2001 to December 2004 and included 178 nonselected patients (108 women and 70 men), with an average age of 56 years (range: 26-77 years) and an average body mass index (BMI) of 30 (range: 26-40). These patients were treated for either abdominal hernia (156 patients; 89.7%) or a primary defect (22 patients; 10.3%). The dimensions of the abdominal hernias treated varied from 4 to 26 cm (average: 12.1 cm). All patients were treated using the laparoscopic technique, and all meshes were placed in the intraperitoneal position. Eleven (7%) postoperative complications arose after an average follow-up period of 29 months (range: 1-48 months): seven seromas (4.4%) lasting for 4 weeks, with one becoming infected after being punctured repeatedly; we removed the infected prosthesis by laparoscopy; three (1.9%) patients with persistent neuralgia, which were resolved after 2 months with a prescription for FANS; one patient with a haematoma at the trocar site. There were also four recurrences (2.5%), all of which occurred between 1 and 3 months postsurgery: one in the 'small' group of abdominal hernias (less than 9 cm) and three in the 'large' group of abdominal hernias. With the exclusion of any primary defects, an adhesiolysis was carried out in 99.3% of the patients. In seven cases (4.4%) we carried out a raphe for speritonealisations of loops in the small intestine; in four patients (2.5%), following tenacious adhesion (one patient) and loops fixed to the previous scar by stitches (three patients), we carried out an intestinal perforation (ileus) which was sutured by laparoscopy. The average operating time was 65.6 min (range: 28-130 min), with an average postoperative period in the hospital of 2.1 days (range: 1-5 days). No conversion was observed, and mortality was zero. The results obtained during the clinical trial demonstrate the safety and efficacy of the laparoscopic technique and of the mesh used as well as the reproducibility of the technique in the intraperitoneal treatment of congenital and postincision defects in the abdominal wall, including those of large dimensions.

Laparoscopic versus open appendectomy in acute appendicitis: a randomized prospective study.

BACKGROUND: Laparoscopic appendectomy is a safe and effective procedure, as both a diagnostic and therapeutic tool. It seems to be more effective than the corresponding open procedure. Aim of this study is to evaluate a group of patients randomly allocated either to laparoscopic appendectomy (LA) or to open appendectomy (OA). METHODS: From January 1998 to December 2002, 252 consecutive and nonselected patients, 155 women and 97 men, were randomized either to LA or OA. Recorded data were operative time, postoperative length, of stay and complications. RESULTS: Mean operative time was 45 min (range 30-120) for OA and 36 min (25-60) for LA, mean postoperative stay was 5.5 days (4-12) for OA and 3.4 days (2-8) for LA. Complication occurred in 20 patients (14.5%) for OA and in four patients (2.6%) for LA. CONCLUSION: We believe that LA is effective in any kind of clinical situation, with low traumatic impact and best comfort for the patient.

[Laparoscopic transabdominal preperitoneal repair of inguinal hernia: indications, technique, complications and results in 10 years experience]. / Ernioplastica inguinale transaddominale preperitoneale laparoscopica. Indicazioni, tecnica, complicanze dopo 10 anni di esperienza.

AIM: Inguinal hernia play a major role in a general surgical division. In the last 10 years laparoscopy has gained a key role even in the treatment of this disease. This study aims to review a single institution's experience with laparoscopic transabdominal preperitoneal repair of inguinal hernia (TAPP). METHODS: A retrospective study of 715 operations in 500 patients from 1992 to September 2002. Two hundred and eight six (56.6%) of these were monolateral hernias and 214 (43.4%) were bilateral while 215 (30%) were recurrent. RESULTS: Of 214 operations recurrence rate was 0.43 with a mean operating time of 30 min (range 25-50) for monolateral hernias and of 70 min (range 45-120) for bilateral hernias. Mean length of stay was 2 days (range 1-10). Return to work occurred in 6 days while sports were resumed after 10 days. Complications occurred in 40 (8.6%) patients with only 2 (0.4%) major complications. Mean follow up time was 58.3 months. CONCLUSION: According to personal experience, and in agreement with international literature, laparoscopy showed to be effective mostly in treating bilateral and recurrent hernias, particularly for faster recovery and less postoperative pain compared to traditional techniques.