Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables.

INTRODUCTION: Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process. METHODS: Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created. RESULTS: 18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed. CONCLUSION: Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy.

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

Robotic rectal resection for cancer: a prospective cohort study to analyze surgical, clinical and oncological outcomes.

AIM: Robotic systems are getting widely spread in recent years given the different technical advantages over traditional laparoscopy. Rectal surgery seems to benefit from this approach, for its ability to easily work in a confined space such as the pelvic cavity. The objective is to present results obtained by the robotic approach in patients with rectal cancer and to give technical considerations. METHOD: Data were prospectively collected in order to evaluate surgical and oncological outcomes. Subjects underwent robotic rectal resection in the period between June 2011 and June 2014 at the Department of Digestive Surgery, "S. Maria" Hospital - Terni (Italy). MAIN OUTCOME MEASURES: Patient characteristics and tumor, overall operative time, conversion to open surgery, site of mini-laparotomy for specimen extraction, intraoperative blood loss, intraoperative complications, time to first bowel movement, time-to-liquid and solid intake, postoperative complications, mortality, hospital stay, thirty-day complications, histopathological examination. RESULTS: 40 consecutive patients underwent robotic resection of the rectum. Median operative time was 340 min (235-460 min), no procedure was converted. Median hospital stay was 5 days (3-18 days). Mesorectum resection was complete in all patients. Median number of harvested lymph nodes was 19 (6-35), median distal resection margin was 4 cm (2-8 cm). CONCLUSION: Robotic rectal surgery is safe and feasible in particular by facilitating the surgeon during the delicate phases of tissue dissection.

Robotic pancreaticoduodenectomy in a case of duodenal gastrointestinal stromal tumor.

BACKGROUND: Laparoscopic pancreaticoduodenectomy is rarely performed, and it has not been particularly successful due to its technical complexity. The objective of this study is to highlight how robotic surgery could improve a minimally invasive approach and to expose the usefulness of robotic surgery even in complex surgical procedures. CASE PRESENTATION: The surgical technique employed in our center to perform a pancreaticoduodenectomy, which was by means of the da Vinci™ robotic system in order to remove a duodenal gastrointestinal stromal tumor, is reported. CONCLUSIONS: Robotic technology has improved significantly over the traditional laparoscopic approach, representing an evolution of minimally invasive techniques, allowing procedures to be safely performed that are still considered to be scarcely feasible or reproducible.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Laparoscopic versus open left colectomy in patients with sigmoid colon cancer: prospective cohort study with long-term follow-up.

BACKGROUND: Laparoscopic left colectomy has obtained a large spread in colon surgery for malignant disease despite the need for an adequate learning curve. However few studies reported long term data in comparison with open left colectomy and most of the authors of large series on colorectal surgery don't describe, in subgroup analysis, results obtained in left colonic resections. The aim of this study is to report the short and long term follow-up of laparoscopic left colon resection in comparison with the open approach, from a single centre, performed in the same timeframe. METHODS: Between January 2005 to January 2007, 55 patients with sigma adenocarcinoma underwent to laparoscopic or open left colectomy at the Department of Digestive Surgery, "S. Maria" hospital in Terni - Italy. Perioperative and histopathological data and results from oncological follow-up, until April 2013, are analyzed. RESULTS: 28 patients underwent laparoscopic left colectomy, while 27 patients open left colectomy. Mean hospital stay was 8.44 ± 1.21 in the laparoscopic group versus 6.86 ± 1.01 in the open group. The histopathological analysis shows a mean of 18.13 ± 6.8 lymph nodes removed after laparoscopy and 13.96 ± 5.72 after open surgery (P = 0.02). Kaplan-Meier analysis does not reveal significative differences in disease free survival (HR = 0.85; 95% CI = 0.21-3.40; P = 0.81). Overall survival up to 5 years shows one death per group. CONCLUSIONS: Laparoscopy, respect to the open approach, could improve perioperative clinical outcomes, hospital stay and harvested lymph nodes with comparable long term oncological follow-up in patients with sigmoid colon cancer.

Laparoscopic single-stapling gastric transection for exophytic pedunculated gastrointestinal stromal tumor: is a safe procedure?

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal tumors of the gastrointestinal tract. The macroscopic growth of these lesions can be intraluminal, extraluminal, or intramural, but only 6 cases in literature report a description of the pedunculated type. A 69-year-old man was admitted to our department after an echocardiographical control revealing, as an incidental consequence, an epigastric mass. Computed tomography and magnetic resonance imaging showed the presence of an oval lesion between the third segment of the liver and the front wall of the gastric antrum, measuring approximately 40 × 30 mm and suspected for pedunculated GIST. We describe the laparoscopic approach performed and the surgical technique that we suggest in similar cases. Although there are still many controversies on the use of laparoscopy in the treatment of gastric GISTs, laparoscopic resection can safely be adopted for an exophytic pedunculated GIST in an institute with experience in minimally invasive surgery.

Robotic right colectomy for cancer with intracorporeal anastomosis: short-term outcomes from a single institution.

PURPOSE: Laparoscopic surgery for colon cancer has widely accepted as safe and effective. However, few studies report outcomes on robotic right colon resection with confectioning of the intracorporeal ileocolic anastomosis. This study aims to evaluate the feasibility and safety of robotic right colon resection with intracorporeal ileocolic anastomosis (RRCIA) in patients with cancer. METHODS: Data of consecutive series of 20 patients undergoing RRCIA between June 2011 and May 2012 at our institution were prospectively collected in order to evaluate surgical and oncological short-term outcomes. RESULTS: Seven males and 13 females were operated of RRCIA during the study period. Mean age is 66.7 years. The mean overall operative time was 327.5 min (255-485), and the robot time was 286 min (range 225-440 min). No conversion to open or laparoscopy occurred. The mean specimen length was 32.7 cm (range 26-44 cm), and the mean number of harvested lymph nodes was 17.6 (range 14-21). During the 30 postoperative days, only one complication occurred, consisting in an infection of surgical specimen extraction wound. CONCLUSION: The RRCIA is a feasible and safe for patients with right colon cancer, also in terms of intraoperative oncological outcomes.