A new fixation-free 3D multilamellar preperitoneal implant for open inguinal hernia repair.

SUMMARY: Between September 2014 and December 2015, 32 patients with inguinal hernia were treated using a new 3D mesh in our department. This mesh is characterized by a multilamellar flower-shaped central core with a flat, large-pore polypropylene ovoid disk that has to be implanted preperitoneally. Compared with the traditional Lichtenstein procedure, we observed a shorter mean duration of surgery and a significantly lower mean visual analogue scale (VAS) postoperative pain score recorded immediately after the procedure in the 3D mesh group. The mean VAS score recoded after 4 and 8 postoperative days showed better results in the 3D mesh group than the control group. Moreover, there was reduced postoperative morbidity in the 3D mesh group than the control group, even if no patients experienced severe complications.

Topical glyceryl trinitrate ointment for pain related to anal hypertonia after stapled hemorrhoidopexy: a randomized controlled trial.

BACKGROUND: Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles. OBJECTIVE: We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy. DESIGN: This was a single-blind, parallel-group, randomized controlled trial. SETTING: The study was conducted at a university teaching hospital in Rome, Italy. PATIENTS: Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded. INTERVENTIONS: Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days. MAIN OUTCOME MEASURES: Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy. RESULTS: Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5 ± 1.0 vs 4.0 ± 1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4 ± 7.4 mmHg vs 85.6 ± 7.9 mmHg, p < 0.0001). LIMITATIONS: GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded. CONCLUSION: Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

Feasibility and safety study of day-case Transtar™ procedure.

BACKGROUND: Short hospitalization surgery is cost effective and convenient for both patients and healthcare system. Stapled transanal rectal resection (STARR) conducted with the new curved device, Contour Transtar, has proved an effective and safe procedure for treatment of obstructed defecation syndrome. The aim of this study was to determine the safety and feasibility of STARR, performed as a day-case procedure. MATERIAL AND METHODS: Retrospective review was performed of all STARR performed as day-case surgery between September 2009 and February 2011. The entire study (intervention, data collection and data analysis) was conducted at the One-day Surgery Unit of the St. Andrea Hospital, Rome, Italy. All patients with surgical indication to STARR for the presence of an obstructed defecation syndrome were included in the study. We excluded from day-case protocol, patients over 65 years old, with an ASA score of III-IV or with a BMI over 35. The surgical technique reflects the original technique proposed by Antonio Longo with the exception of the longitudinal prolapse opening, which was created with the use of an electric scalpel between two Kocher clamps and not by an application of Transtar stapler. To evaluate the feasibility and safety of performing this procedure with short hospitalization, we investigated the presence and the time of presentation of post-operative complications. RESULTS: Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission. CONCLUSIONS: STARR performed with Contour Transtar, in selected patients, is safe and feasible in day-case regimen if performed by expert surgeons and in a structure that allows the physician to keep the patient hospitalized or to re-admit and promptly treat those patients who present major surgical complication.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

Stapled anopexy as a day surgery procedure: our experience over 400 cases.

BACKGROUND: In 1988, Longo proposed a new treatment for haemorrhoidal disease. In western countries day surgery procedures are becoming more and more common. We propose a new protocol for outpatient haemorrhoidopexy. PATIENTS AND METHODS: From 2003 to 2010, we performed 403 out-patient stapled haemorrhoidopexies under spinal anaesthesia, on patients with symptomatic grade III and IV haemorrhoid disease. We used PPH 01 and PPH 03 staplers (Ethicon Endosurgery, Cincinnati, OH, USA). We assessed early and late postoperative pain with a Visual Analogue Scale (VAS), and clinical postoperative examinations were performed 7 days, 6 months, and 1, 3 and 5 years after surgery. RESULTS: The mean surgery time was about 20 min (range 13-39 min). Out of 403 patients, 41 were not dischargeable as a result of urine retention, severe pain or mild bleeding. Twenty-two patients reported transient faecal urgency, while no patient complained of anal incontinence. CONCLUSIONS: Our experience with 403 patients demonstrated that stapled haemorrhoidopexy is feasible and safe as a day surgery procedure. However, careful preoperative planning is necessary in order to evaluate the patients' health status and the consequent perioperative and postoperative risk. Our results are positive in terms of surgical safety and postoperative recovery time.

Modified technique for performing STARR with Contour Transtar™.

Stapled Transanal Rectal Resection (STARR) performed using CCS-30 Contour Transtar™ despite its recent introduction seems to be an effective surgical procedure to treat obstructed defecation syndrome. The major constraint of this procedure is the need to open the prolapse longitudinally using the CCS-30. This is often difficult and can lead to an inadequate or spiralling resection. Our modified technique, presented in this paper, creates the prolapse opening with an electric scalpel between two Kocher clamps, placed to grab the whole prolapsed tissue at 2 and 4 o'clock, respectively. The results of the first 83 procedures confirm that this technique allows the surgeon to simplify the prolapse's longitudinal opening and especially the first loading of the tissue between the CCS-30 jaws, which is necessary to start the circular resection, as confirmed by the absence of spiralling and major complications in this series.

Laparoscopic assisted transvaginal cholecystectomy: single centre preliminary experience.

BACKGROUND: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a new approach that allows abdominal surgery to be performed through a natural orifice such as the oral cavity, vagina or rectum. We present our preliminary experience of laparoscopic assisted transvaginal cholecystectomy (LATC). METHODS: Women affected by cholelithiasis, age below 65 years, BMI under 30, ASA I or II, previous full-term pregnancies, and without previous abdominal surgery underwent LATC. Patients' biographic data, operative time, intraoperative and postoperative complications were collected. RESULTS: We performed 21 LATCs. Median operative time was 58 min. There were no intraoperative complications. The postoperative course was uneventful in all patients. At 1 year there were no complications and no impaired sexual activity. CONCLUSIONS: The results of NOTES are promising, but currently only hybrid NOTES can be safely performed. LATC seems to guarantee better cosmetic results, less postoperative pain, faster mobilization and shorter hospitalization than laparoscopic cholecystectomy.

Laparoscopic cholecystectomy in day surgery: feasibility and outcomes of the first 400 patients.

BACKGROUND: The aim of this study was to evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in a day surgery setting in Italy. MATERIAL AND METHODS: Between March 2003 and June 2011, in our institution 439 patients were selected for day surgery LC. To evaluate the efficacy and safety of the procedure, postoperative complications, pain, nausea and vomiting were monitored at 4, 8, and 24 h after surgery. Patients admitted for an overnight stay or readmitted after discharging were also monitored. RESULTS: Over 8 years we performed 400 LC in day surgery setting and no conversion or major intraoperative complication were detected. A total of 387 patients (96.7%) were successfully discharged after 8-10 h of observation. Postoperative monitoring showed good pain control (mean VAS score 1.5) and only 3 (0.7%) of the 7 patients who experienced major pain were admitted. Twenty-seven patients (6.7%) experienced PONV and 9 (2.2%) of these required admission. None of the patients needed to be readmitted after discharging. The satisfaction questionnaire administered at 1 month office visit showed that 380 patients (95%) were satisfied with day surgery LC. CONCLUSIONS: Our success rate of 96.7% can be attributed to strict adherence to the patient selection criteria. The main reasons for hospital admission were pain and PONV; adequate control of these represents the key of success for day surgery LC. This study confirms the feasibility and safety of LC performed in day surgery setting.

The use of bioabsorbable staple-line reinforcement performing stapled hemorrhoidopexy to decrease the risk of postoperative bleeding.

Postoperative staple-line bleeding after stapled hemorrhoidopexy represents a major issue of this procedure, especially in the day surgery setting. In this study we assess the possible benefit of using circular bioabsorbable staple-line reinforcement to reduce the risk of hemorrhage when performing stapled hemorrhoidopexy in a day surgery setting. Patients with symptomatic II to III grade hemorrhoidal disease were randomly assigned into two groups. In Group A we performed a stapled hemorrhoidopexy using PPH33-03(®) with Seamguard(®), a bioabsorbable staple-line reinforcement; in Group B, we used only a PPH33-03(®) stapler. We evaluated the intraoperative and postoperative staple-line bleeding and, secondarily, the duration of surgery, need for additional hemostatic stitches, and presence of postoperative complications. One hundred patients were enrolled in the study. Group A patients showed a statistically significant decrease of intraoperative bleeding (4 vs 42% in Group B) and hemostatic stitch placement (5.7 vs 42%) with the consequent reduction in mean operative time, postoperative pain, and tenesmus. There were no differences between the two groups in hemorrhoidal disease control or postoperative late complications. The use of bioabsorbable staple-line reinforcement while performing stapled hemorrhoidopexy may allow improvement of the safety of this procedure, especially in a day surgery setting.

[Gastric pacing to treat morbid obesity: two years experience in four patients]. / Il gastric pacing per il trattamento dell'obesità patologica. Esperienza a due anni in 4 pazienti.

BACKGROUND: Gastric pacing to treat morbid obesity has been found to be safe and the implant technique simple to perform. Appetite is reduced and satiety is increased after the implant. There are two components in the Implantable Gastric Stimulation (IGS): (a) an electrical stimulator connected to a (b) bipolar lead that is positioned in the muscle wall of the stomach. We describe the optimal procedure to safely place the components. We present our results after preliminary experiences. METHODS: From August 2005 to January 2006, 4 patients (F) mean age 44 (33-63) underwent to IGS implant. The mean BMI was 41.8 (378-47), mean weight 117.2 Kg (107-133) . The IGS was activated 30 days after implant. Fasting and postprandial plasma ghrelin concentrations after a test meal were measured before and 1, 2, 3 and 6 months after implanting operation. RESULTS: All procedures were successfully completed laparoscopically. There were no major operative complications. Postoperative course was uneventful in all cases. One patient was lost to follow up after six months. Postoperative lead dislodgement and cutaneous decubitus occurred in another patient, making necessary the removing of the device. For the other two patient only in one there was a significant weight loss (49 Kg), in the second weight was unchanged. Plasma ghrelin concentrations were no correlated among patients, and results were not in line with what waited by the producer. CONCLUSION: Morbid obese patients can undergo IGS implantation by laparoscopy with minimal perioperative complications. Attention to technical details is essential. In accordance with the producer (Medtronic) our data demonstrate that gastric pacing is a safe procedure for selected patients supported by adequate psychological treatment, but outcome about weight loss should be evaluated among bigger trial, as our experience didn't give satisfactory results, and therefore discouraged us to carry on with the study.

Is desmoplasia a protective factor for survival in patients with colorectal carcinoma?

BACKGROUND & AIMS: The role of desmoplasia in colorectal carcinoma progression is unclear and the presence of collagen stroma may represent a barrier against cancer diffusion and vascular invasion or a stroma to build up and support the tumor. The aim of this study was to evaluate the effect of desmoplastic response on long-term survival of patients who underwent radical resection for colorectal carcinoma. METHODS: The study included 429 patients who underwent radical colorectal resection for cancer with a median follow-up period of 72.8 months. RESULTS: At univariate analysis significant associations were observed between desmoplasia and histologic type, parietal infiltration, growth pattern, and staging. No associations were found between desmoplasia and the other clinical and histologic parameters. The multivariate analysis stratified for tumor stage revealed that the factor showing the most favorable influence on time to death was desmoplasia. The presence of desmoplasia was likely to decrease the failure rate to a third of the rate experienced by patients without desmoplasia. Parietal infiltration was associated with an increased risk for a shortened time to death. CONCLUSIONS: Our results favor the view that desmoplasia is a protective factor for survival in patients with colorectal carcinoma. This finding is consistent with the hypothesis that desmoplasia may prevent cancer invasiveness by building a barrier against tumor diffusion.