A Nutraceutical Combination of Bromelain and Boswellia Serrata Casperome® in Siben®: Effects on the Postoperative Course of Inguinal Hernioplasty with Mesh at One Year Follow up. A Randomized Multicentric Study.

AIM: We investigated the potential benefits of administering a nutraceutical combination of Bromelain (200 mg) and Boswellia serrata Casperome® (200 mg) on post-operative outcomes of hernioplasty with mesh. METHODS: One hundred eighty patients (27 females, 153 males) were enrolled to undergo open tension-free hernioplasty with the use of Progrip®. Patients were randomized to receive either one tablet of Siben® (study group) or placebo (control group) on an empty stomach, every twelve hours for eleven postoperative days. All patients filled out a medical questionnaire focused on postoperative pain, based on the Visual Analogue Scale (VAS) scale and the Short Form-36 (SF-36) questionnaire, at time T0 (day of surgery) and T28 (28th day after surgery). RESULTS: One-year results showed a significant improvement in the primary postoperative outcome in the study group. Perception of pain was significantly reduced in the Siben® group compared with controls, both on the seventh (p < 0.05) and the twenty-first (p < 0.05) postoperative day. Patients included in the Siben® group also resumed daily activities and returned to work earlier than the controls. Moreover, results of the SF-36 indicated better Quality of Life (QoL) scores in the study group compared to the placebo group. CONCLUSIONS: Our analysis effectively demonstrates that the use of Siben® in open inguinal hernia mesh repair may improve short- and long-term surgical outcomes, contributing to a better QoL.

Non-hereditary early onset gastric cancer: An unmet medical need.

Gastric cancer (GC) is a lethal disease and the diagnosis in the young population is a major challenge from both individual and social point of views. Early-onset GC accounts for ∼5% of GC; among them, 3% are part of a hereditary syndrome and the majority are sporadic. However, even if the early-onset forms were less frequent in the past, the increasing number in the last decades has improved the interest and awareness of them in the society and in the scientific community. In particular, the different behaviour and characteristics of early-onset GC suggest that it is a completely different entity, which requires a tailored and personalized management. Here we provide an updated overview about non-hereditary early-onset GC, which is an unmet clinical need today, along with future perspectives in this field.

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases.

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m2) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6-30) and mean defect area was about 267.9 cm2. Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Recurrent convulsive syncope misdiagnosed as seizures due to a diaphragmatic hernia.

Differential diagnosis of seizures and convulsive syncope may be challenging in clinical practice. Furthermore, a misleading diagnosis of epilepsy may be detrimental for the patient as it often implies an over-prescription and an over-use of antiepileptic drugs which can cause adverse reactions. Moreover, a wrong diagnosis also causes distress to the patient with the risk of performing plenty of investigations without any benefits on the symptoms. In this case, we present a 57-year-old patient suffering from recurrent convulsive syncope over the last 7 years for which he underwent several cardiological and neurological tests and took plenty of antiepileptic drugs without any benefits on his convulsive episodes with loss of consciousness. During hospitalization, a chest X-ray was performed revealing an unknown diaphragmatic hernia with eventration of the transverse colon in the right hemitorax and mild cardiac compression. The patient underwent laparotomic surgery and diaphragmatic reconstruction with complete recovery. After 6-month follow-up, the patient no longer had episodes of convulsive syncope.

Efficacy of Surgery for the Treatment of Gastric Cancer Liver Metastases: A Systematic Review of the Literature and Meta-Analysis of Prognostic Factors.

BACKGROUND: In the last 10 years, the management of patients with gastric cancer liver metastases (GCLM) has changed from chemotherapy alone, towards a multidisciplinary treatment with liver surgery playing a leading role. The aim of this systematic review and meta-analysis is to assess the efficacy of hepatectomy for GCLM and to analyze the impact of related prognostic factors on long-term outcomes. METHODS: The databases PubMed (Medline), EMBASE, and Google Scholar were searched for relevant articles from January 2010 to September 2020. We included prospective and retrospective studies that reported the outcomes after hepatectomy for GCLM. A systematic review of the literature and meta-analysis of prognostic factors was performed. RESULTS: We included 40 studies, including 1573 participants who underwent hepatic resection for GCLM. Post-operative morbidity and 30-day mortality rates were 24.7% and 1.6%, respectively. One-year, 3-years, and 5-years overall survival (OS) were 72%, 37%, and 26%, respectively. The 1-year, 3-years, and 5-years disease-free survival (DFS) were 44%, 24%, and 22%, respectively. Well-moderately differentiated tumors, pT1-2 and pN0-1 adenocarcinoma, R0 resection, the presence of solitary metastasis, unilobar metastases, metachronous metastasis, and chemotherapy were all strongly positively associated to better OS and DFS. CONCLUSION: In the present study, we demonstrated that hepatectomy for GCLM is feasible and provides benefits in terms of long-term survival. Identification of patient subgroups that could benefit from surgical treatment is mandatory in a multidisciplinary setting.

How to Treat Hepatocellular Carcinoma in Elderly Patients.

Hepatocellular carcinoma (HCC) is the primary tumour of the liver with the greatest incidence, particularly in the elderly. Additionally, improvements in the treatments for chronic liver diseases have increased the number of elderly patients who might be affected by HCC. Little evidence exists regarding HCC in old patients, and the elderly are still underrepresented and undertreated in clinical trials. In fact, this population represents a complex subgroup of patients who are hard to manage, especially due to the presence of multiple comorbidities. Therefore, the choice of treatment is mainly decided by the physician in the clinical practice, who often tend not to treat elderly patients in order to avoid the possibility of adverse events, which may alter their unstable equilibrium. In this context, the clarification of the optimal treatment strategy for elderly patients affected by HCC has become an urgent necessity. The aim of this review is to provide an overview of the available data regarding the treatment of HCC in elderly patients, starting from the definition of "elderly" and the geriatric assessment and scales. We explain the possible treatment choices according to the Barcelona Clinic Liver Cancer (BCLC) scale and their feasibility in the elderly population.

An exercise-based educational and motivational intervention after surgery can improve behaviors, physical fitness and quality of life in bariatric patients.

INTRODUCTION: Unhealthy lifestyles may hinder bariatric surgery outcomes. This non-randomized controlled study aimed to evaluate the effects of an integrated post-operative exercise-based educational and motivational program in improving behaviors, quality of life, anthropometric features, cardiorespiratory and physical fitness in bariatric patients respect to the only surgical intervention. METHODS: A group of adult sedentary bariatric patients chose to attend a 12-month exercise program integrated with diet education and motivational support, or to receive usual care. Dietary habits, binge eating disorder, physical activity, obesity-related quality of life, Body Mass Index, waist and hip circumference, VO2max, strength and flexibility were assessed at the start and at the end of the study in both groups. RESULTS: On a total of 82 patients enrolled, follow-up measures were obtained from 28 (85.7% females, mean age 38.2±8.7) and 42 (71.4% females, mean age 40.2±9.5) patients included in the intervention and control group, respectively. All the behavioral and physical outcomes improved significantly in the participants to the intervention, while the control group showed lesser changes, especially regarding quality of life and physical fitness. CONCLUSIONS: Notwithstanding the self-selection, these results suggest that a timely postoperative behavioral multidisciplinary program for bariatric patients may be effective in establishing healthy behaviors which can lead to better surgery outcomes.

Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia.

OBJECTIVES: Acute mesenteric ischemia (AMI) is a gastrointestinal and vascular emergency in which the detection of patients requiring intestinal resection is mandatory. METHODS: Registered data of 55 consecutive patients admitted to our center between January 2010 and December 2016 that underwent an explorative laparotomy for a suspected diagnosis of irreversible transmural intestinal necrosis (ITIN) were analyzed. Demographic, clinical, laboratory and CT findings were statistically analyzed in order to search predictive factors of ITIN and their correlation to its clinical spectre. RESULTS: Tobacco use was the most statistically significant (p<0.01) cardiovascular disease risk factor involved in ITIN. Among lab tests, Serum lactate levels ˃ 2mmol/L resulted in a statistically significant association with ITIN (p=0.0001). Organ failure (defined as Marshall score> 2) and the three main CT findings (decreased bowel wall enhancement, bowel loop dilation and demonstrated vessel occlusion) were strongly associated with ITIN (p values: 0.001, 0.007, 0.0013, 0.0005). Only serum lactate levels>2 mmol/L resulted as statistically significant as predictive factors of ITIN in multivariate analysis using logistic regression (OR 49.66 and p-value 0.0021). CONCLUSION: Our univariate and multivariate analysis identified multiple factors (Serum lactate levels ˃ 2mmol/L, Organ failure, CT signs) that could suggest patients that require a surgical approach for ITIN.

Retrospective Comparison of Single-Port Sleeve Gastrectomy Versus Three-Port Laparoscopic Sleeve Gastrectomy: a Propensity Score Adjustment Analysis.

PURPOSE: Evaluate the efficacy of single-port sleeve gastrectomy (SPSG) and then compare it to a less-invasive sleeve approach (three-port) (3PSG) according to a propensity score (PS) matching analysis. MATERIALS AND METHODS: We analyzed all patients who underwent SG through a three-port or a single-port laparoscopic approach. RESULTS: After 2 years, the follow-up was completed in 84% patients treated with 3PSG and 95% patients of the SPSG group. Excess weight loss (EWL) was comparable for the first year of follow-up within the two groups except for the controls at 3 months in which the SPSG group showed a higher EWL (p = 0.0243). CONCLUSION: We demonstrated the efficacy of SPSG in bariatric surgery even compared to another, less invasive, laparoscopic SG approach (three-port).

Efficacy and safety of ultrasound-guided placement of central venous port systems via the right internal jugular vein in elderly oncologic patients: our single-center experience and protocol.

BACKGROUND: Ultrasound-guidance has become the routine method for internal jugular vein (IJV) catheterization reducing dramatically failure and complication rates for central venous port (CVP) placement. AIMS: The aim of this study was to determine the safety and efficacy of ultrasound-guided IJV CVP placement in elderly oncologic patients. METHODS: Between January 2013 and December 2015, 101 elderly oncological patients underwent right IJV CVP placement under ultrasound-guidance. The length of catheter introduction ranged from 18 to 21 cm. Intraoperative fluoroscopy (IF) was always performed intraoperatively. Chest X-ray (CXR) was always performed 30 min after the end of the procedure. RESULTS: The morbidity rate was 1.98%; two arterial punctures were reported with one self-limiting hematoma. Two patients (1.98%) had catheter misplacements, recognized by intraoperative IF. No patients (0%) experienced pneumothorax (PNX), confirmed at CXR. Patients were all discharged at maximum 6 h from the procedure. DISCUSSION: The risk of catheter misplacement, PNX, and arterial/nerve puncture remains present with this technique. Lower rates of catheter misplacement have been reported after right IJV puncture, probably for its straight vertical course. Our results are in accordance with literature (1 counter-lateral subclavian vein and 1 counter-lateral internal jugular vein misplacements). All misplacements were detected intraoperatively. The PNX rates after cannulation of the IJV vary between 0.0 and 0.5%. We had no PNX occurrence. CONCLUSION: Ultrasonography (US) has improved safety and effectiveness of port system placements. While routine post-procedural CXR seems avoidable, IF should be considered mandatory.

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature.

BACKGROUND: Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment. METHOD: Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed. DISCUSSION: Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise. CONCLUSION: The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach.

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.