Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC). METHODS: MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. RESULTS: Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD -0·97, 95% of c.i. -1·51 to -0·43; P < 0·001) and Cosmesis score (WMD -2·46, 95% of c.i. -2·95 to -1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used. CONCLUSION: SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety.

Is inferior mesenteric artery ligation during sigmoid colectomy for diverticular disease associated with increased anastomotic leakage? A meta-analysis of randomized and non-randomized clinical trials.

AIM: A meta-analysis was conducted to compare preservation with ligation of the inferior mesenteric artery (IMA) during sigmoidectomy for diverticular disease. METHOD: Randomized and non-randomized clinical trials were identified using the following electronic databases: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, Science Citation Index, Greynet, SIGLE, National Technological Information Service, British Library Integrated Catalogue. The analysed end-points were the anastomotic leakage rate, overall morbidity and 30-day postoperative mortality. RESULTS: Four studies were included involving 400 patients. The anastomotic leakage rate was 7.3% in the preservation group and 11.3% in the ligation group. There was no statistically significant difference between the groups (OR 0.72, 95% CI 0.11-4.76; P=0.73). Overall morbidity and 30-day postoperative mortality were not compared since these data were reported in only one study. CONCLUSION: The meta-analysis did not show any advantage for preservation of the IMA during sigmoid colectomy for diverticular disease in terms of anastomotic leakage.

Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies.

AIM: The aim of this systematic review was to compare laparoscopic and/or laparoscopic-assisted right colectomy (LRC) with open right colectomy (ORC). Many randomized clinical trial have shown that laparoscopic colectomy benefits patients with improved short-term outcomes and comparable overall survival in respect to the open approach. These results, however, could not be applied to right colectomy owing to its wide range of resection and more complicated vascular regional anatomy. METHOD: We performed a meta-analysis of the literature in order to compare LRC vs ORC by examining 21 end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing right colectomy for cancer was carried out. The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement. The search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL until March 2011. We included randomized and non randomized studies that compared the LRC vs ORC for benign disease and malignant neoplasm irrespective of publication status. Only studies in English, French, German, Spanish and Italian languages were considered for inclusion. Emergency right colectomies were excluded. To perform the statistical analysis we used the odds ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. An intention-to-treat analysis was performed. RESULTS: Seventeen studies, 15 nonrandomized clinical trials and two randomized clinical trials, involving a total of 1489 patients, were identified. The mean operative time was longer in the group of patients undergoing LRC [weighted mean difference (WMD) = 37.94, 95% CI: 25.01 to 50.88; P < 0.00001]. Intra-operative blood loss (WMD = -96.61; 95% CI: -150.68 to -42.54; P = 0.0005), length of hospital stay (WMD = -2.29; 95% CI: -3.96 to -0.63; P = 0.007) and short-term postoperative morbidity (OR = 0.64; 95% CI: 0.49 to 0.83; P = 0.0009) were significantly in favour of LRC. CONCLUSION: Laparoscopic-assisted right colectomy results in less blood loss, a shorter length of hospital stay and lower postoperative short-term morbidity compared with ORC.

Sentinel lymph node biopsy under local anaesthesia versus general anaesthesia: reliability and cost-effectiveness analysis in 153 patients with malignant melanoma.

AIM: The aim of our study was to evaluate feasibility, reliability and cost-benefit balance of sentinel node (SN) biopsies conducted under local anaesthesia (LA) in patients affected by stage I-B or II cutaneous melanoma. PATIENTS AND METHODS: A retrospective analysis was carried out in 153 patients, evaluating the number of harvested lymph nodes, perioperative and postoperative complications, operating time and operating room costs, comparing interventions under LA and general anaesthesia (GA). Operations were carried out under LA in 112 cases (73%) and under GA in the remaining 41(27%). RESULTS: The mean number of removed SN was overall higher in the GA group but was not significantly different under LA with respect to the subgroups of axillary biopsies. No difference was noted in the number of complications. Operating time was significantly shorter under LA, with significantly lower costs. CONCLUSION: LA for groin and axillary SN biopsies can be a reliable and effective alternative to GA in melanoma patients, with shorter operating time, lower costs and without the side-effects and risks associated with GA.

Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials.

AIM: Laparoscopic and open rectal resection for cancer were compared by analysing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long-term oncological outcomes. METHOD: We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer using the following electronic databases: PubMed, OVID, Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Nine randomized clinical trials (RCTs) were included in the meta-analysis incorporating a total of 1544 patients, having laparoscopic (N = 841) and open rectal resection (N = 703) for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier resuming solid diet, return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of post-operative abdominal bleeding, late intestinal adhesion obstruction and late morbidity. No differences were found in terms of intra-operative and late oncological outcomes. CONCLUSION: The meta-analysis indicates that laparoscopy benefits patients with shorter hospital stay, earlier return of bowel function, reduced blood loss and number of blood transfusions and lower rates of abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidities.

Prognostic role of sentinel node biopsy in patients with thick melanoma: a meta-analysis.

OBJECTIVES: Sentinel lymph node (SLN) biopsy is a prognostic tool for patients with intermediate-thickness melanomas. However, controversies exist regarding its role in patients with thick melanomas (tumour thickness greater than 4.0 mm). We performed a meta-analysis to assess the prognostic role of SLN in thick melanoma in terms of disease-free survival (DFS) and overall survival (OS). METHODS: An electronic search in MEDLINE and EMBASE databases using the terms 'melanoma' and 'sentinel lymph node' was performed. Studies were considered if they reported data on thick melanoma and SLN biopsy results (positive and negative) and outcomes (DFS or OS). A proportion meta-analysis was used to calculate weighted means and an incidence rate ratio meta-analysis was used to compare outcomes according to SLN biopsy results. RESULTS: Nine studies were included. The weighted mean thickness of melanoma was 4.4 mm, 42% of patients had ulcerated melanoma. SLN was positive in 36% of the patients. Overall, DFS was 71% in patients with a negative SLN and 39% in patients with a positive SLN after a median follow-up of 33 months (IRR 1.83, 95% CI = 1.56-2.14). OS was 71% in patients with a negative SLN and 49% in patients with a positive SLN (IRR 1.44, 95% CI = 1.25-1.65). CONCLUSIONS: The results of this analysis showed that thick melanoma patients with a positive SLN had a significantly worse survival compared with SLN negative patients, thus supporting the routine adoption of SLN biopsy as a prognostic tool also for this subgroup of patients.

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis.

AIM: The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. METHOD: The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39-0.98). CONCLUSION: Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome.

AIM: The study aimed to compare robotic rectal resection with laparoscopic rectal resection for cancer. Robotic surgery has been used successfully in many branches of surgery but there is little evidence in the literature on its use in rectal cancer. METHODS: We performed a systematic review of the available literature in order to evaluate the feasibility, safety and effectiveness of robotic versus laparoscopic surgery for rectal cancer. We compared robotic and laparoscopic surgery with respect to twelve end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing full-robotic or robot-assisted rectal resection and robotic total mesorectal excision was carried out. All aspects of Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement were followed to conduct this systematic review. Comprehensive electronic search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL. Randomized and nonrandomized clinical trials comparing robotic and laparoscopic resection for rectal cancer were included. No language or publication status restrictions were imposed. A data-extraction sheet was developed based on the data extraction template of the Cochrane Group. The statistical analysis was performed using the odd ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. RESULTS: Eight non randomized studies were identified that included 854 patients in total, 344 (40.2%) in the robotic group and 510 (59.7%) in the laparoscopic group. Meta-analysis suggested that the conversion rate to open surgery in the robotic group was significantly lower than that with laparoscopic surgery (OR = 0.26, 95% CI: 0.12-0.57, P = 0.0007). There were no significant differences in operation time, length of hospital stay, time to resume regular diet, postoperative morbidity and mortality, and the oncological accuracy of resection. CONCLUSION: Robotic surgery for rectal cancer has a lower conversion rate and a similar operative time compared with laparoscopic surgery, with no difference in recovery, oncological and postoperative outcomes.

The sentinel node biopsy in patients with thick melanoma: outcome analysis from a single-institution database.

BACKGROUND: We examined the impact of sentinel lymph node (SLN) biopsy among patients with primary melanoma that exceeded 4.0 mm in Breslow thickness, treated in our Institution from 1998 until 2009. PATIENTS AND METHODS: According to Kaplan-Meier statistics, overall survival (OS) and disease-free survival (DFS) were assessed in patients with: i) disseminated disease at diagnosis with respect to patients undergoing SLN biopsy and ii) positive SLN and negative SLN. The effect of age, thickness and number of positive SLN on survival was also calculated. RESULTS: Forty-three patients with thick melanoma were included (29 men and 14 women; mean age 65 ± 17 years, tumor thickness ranging from 4 to 20 mm). Thirteen patients (30%) were not eligible for SLN biopsy due to metastatic disease or poor clinical condition. Biopsy was performed on 30 patients: 14 with positive SLN (46.7%, group A) and 16 with negative SLN (53.3%, group B). Seven patients (50%) died in group A and 2 patients (13%) in group B (mean follow-up 28 and 59 months, respectively); all 7 patients in group A and no patient in group B died because of melanoma. OS and DFS were both significantly higher in group B than group A. CONCLUSION: Our experience demonstrates a high rate of positive SLNs in patients with thick melanoma, and significant differences regarding the general outcomes between those with positive and negative SLNs, the latter group having a good prognosis despite the thick primary tumor. This observation stresses the importance of SLN biopsy as a staging tool in patients with thick melanoma.

[Colorectal cancer in the elderly: which surgical approach?]. / Carcinoma colo-rettale nell'anziano: quale approccio chirurgico?

Single-operator case studies of 135 patients undergoing surgery for colon rectal carcinoma (CRC) between June 2004 and April 2008 in our Institute. Patients were divided into two groups (A: < 70 years old, n = 44, - = 27 U = 17, B: ≥ 70 years old, n = 91, - = 49 U = 42) and were compared clinical, pathological and surgical data. In particular, were analyzed age range and average age, ASA score, post-operative complications (major and minor), mortality at 30 days. Surgical procedure with radical intent (R0) was achieved in 41 (93%) and 76 (83%) patients respectively in group A and B; Given the more than double the number in group B than in group A is easy to imagine that for equal numbers in both groups might have observed an almost equal R0 resections in both groups; Despite the uneven number of groups A and B, it was noted that age is not a factor in determining the surgical therapeutic strategy in the CRC, as well as the clinical conditions of patients.

[The sentinel lymph node mapping in colon cancer]. / Il linfonodo sentinella nei tumori del colon.

BACKGROUND: malignant tumors of the colon can metastases along the lymphatic system in a sequential way, which means that there will be a first node to be involved and then from this disease will pass to another node and so gradually. The sentinel lymph node is the first lymph node or group of nodes reached by metastasizing cancer cells from a tumor. OBJECTIVES: the present work aims to determine the predictive value of the sentinel lymph node procedure in the staging of non-metastatic colon cancer. PATIENTS AND METHODS: in this prospective study joined up only 26 patients with adenocarcinoma of the colon T2-T3, without systemic metastases, and with these criteria for inclusion: a) minimum age: 18 years old; b) staging by total colonoscopy, chest X-ray and CT scan; c) patients classified as ASA 1-3; d) informed consent. Within 20 minutes from the colic resection, the bowel was cut completely along the antimesenteric margin and is performed submucosal injection of vital dye within 5 mm from the lesion at the level of the four cardinal points; then the lymph nodes are placed in formalin and sent to the pathologist. The lymph nodes were subjected to histological examination with haematoxylin-eosin and with the immunohistochemistry technique. RESULTS: from January to December 2008 only 26 patients joined up in this prospective study. From the study were excluded the 4 patients with T4 and M1 tumour. Also 7 patients with stenotic lesions were excluded. Patients considered eligible for our study were only 14. The histopathological examination of haematoxylin-eosin revealed: a) in 4 cases were detected mesocolic lymph node metastases; b) in 10 cases were not detected mesocolic lymph node metastases. In cases there were no metastases, the mesocolic sentinel lymph nodes lymph nodes were examined with immunohistochemical technique; in 2 cases were revealed the presence of micrometastases. In one case was identified aberrant lymphatic drainage patterns (skip metastasis); the sentinel lymph node (negative examination wit eaematoxylin-eosin) was studied with immunohistochemical technique that has not revealed the presence of micrometastases. CONCLUSIONS: the examination of the sentinel node is feasible with the ex vivo method. Using the immunohistochemical technique we detect micrometastasis in 20% of the cases, not revealed with the classical haematoxylin-eosin examination. The study of sentinel lymph node with multilevel microsections and immunohistochemical techniques allow a better histopathological staging.

[The abdominal compartment syndrome and the importance of decompressive re-laparotomy]. / La sindrome compartimentale addominale ed il ruolo della re-laparotomia decompressiva.

BACKGROUND: the Abdominal Compartment Syndrome (ACS) is an increasingly recognized complication of both medical and surgical patients. The World Society of the Abdominal Compartmental Syndrome defined Intra Abdominal Hypertension (IAH) as a mean Intra Abdominal Pressure (IAP) ≥ 12 mm Hg and the ACS as IAP ≥ 20 mmHg (with or without an abdominal perfusion pressure < 60 mm Hg) that is associated with dysfunction or failure of one or more organ systems that was not previously present. The IAH contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of ACS. OBJECTIVES: This study aims to investigate the clinical significance of IAH, the prevalence of ACS and the importance to the effects to the abdominal decompressive re-laparotomy. Patients and methods. The study included 10 patients, 4 men and 6 women with an average age of 68 years (range, 38-86) operated and and treated with xifo-pubic laparotomy between January 2007 and December 2008. According to gold-standard methods, we measured the IAP by indirect measurement using the transvescical route via Foley bladder catheter. RESULTS: among 10 patients with laparotomy, 8 patients (80%) developed IAH < 20 mm Hg but they have not reported significant organ dysfunction , while 2 patients (20%) developed an IAH > 20 mm Hg associated whit organ dysfunction. For this reason, the last 2 patients were undergoing to the decompressive re-laparotomy with temporary closure. CONCLUSION: in according to our experience and the results of the literature, we believe essential monitoring abdominal pressure in patients with abdominal laparotomy. The abdominal decompressive re-laparotomy is a useful procedure to reduce symptoms and improve the health of the patient.

Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis.

BACKGROUND: Sphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt. METHODS: We performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses. Clinically relevant events were grouped into four study outcomes: general outcome measures: dehydratation and wound infection GOM construction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhage closure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and hernia functioning of the stoma outcome measures: occlusion and skin irritation. RESULTS: Twelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes. CONCLUSION: Our overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.

Endothelial progenitor cells are mobilized after major laparotomic surgery in patients with cancer.

The progression of cancer is largely dependent on neoangiogenesis. Circulating endothelial progenitor cells (EPC) have the ability to form complete vascular structures in vitro and play a crucial role in tumor vasculogenesis. Emerging evidence suggests that surgical injury may induce the mobilization of EPC in animal models, and this might have a negative effect on the prognosis of cancer patients. We studied 20 patients (10 men, 65+/-13 years) undergoing laparotomy for surgical treatment of various forms of abdominal cancer, and 20 age- and sex-matched healthy control subjects. The number of circulating EPC, defined as CD34+/KDR+ cells identified among mononuclear cells isolated from peripheral venous blood, was determined preoperatively and at days 1 and 2 after surgery. Surgery induced a significant increase in circulating EPC levels at day 1 (from 278/mL, interquartile range 171-334, to 558/mL, interquartile range 423-841, p<0.001) and day 2 (709/mL, interquartile range 355-834, p<0.001)compared with baseline values. EPC levels did not change in control subjects. Seven subjects who underwent laparotomic surgery for non-neoplastic disease also showed an increase in EPC levels after surgery (p=0.009 and p=0.028 at day 1 and day 2, respectively). We conclude that patients undergoing elective laparotomic surgery for cancer demonstrate an increase in EPC post-operatively. The potential adverse effects of surgical stress-induced EPC mobilization on tumor and metastasis growth in cancer patients need to be addressed in future studies.

[Cholecysto-gastric fistulas: case report and literature revision]. / Le fistole colecisto-gastriche. Descrizione di un caso e revisione della letteratura.

Authors report a recent case of cholecysto-gastric fistula. On the basis of their own experience and of the literature, authors discuss the pathogenesis of the cholecysto-enteric fistulas and underline the relative non frequent of fistulas with the stomach. Authors stress the available diagnostic and therapeutic features and believe that this disease deserves, whenever possible, a surgical correction.

Nipple-sparing mastectomy. Preliminary results.

Nipple-sparing mastectomy (NSM) combines a skin-sparing mastectomy with preservation of the Nipple Areola Complex (NAC), intraoperative pathological assessment of the nipple tissue core, and immediate reconstruction, thereby permitting better cosmesis for patients undergoing total mastectomy. Radiotherapy of the NAC was carried out in every single patient after surgery. The procedure was first performed on selected patients following a clinical research protocol. From January 2003 to June 2004, 10 patients underwent nipple sparing mastectomy followed by reconstruction (4 of them decided also to undergo a prophylactic mastectomy on the other breast) at the Breast Unit, Policlinico Monteluce, Perugia, Italy. Patients had been accurately selected before the operation following some criteria previously assessed by a team of specialists including the breast surgeon, the oncological physician, the radiotherapist and the plastic surgeon. Histology of the 10 NSMs confirmed invasive carcinoma in 3 cases and in situ carcinoma in the remainder. Superficial necrosis of the NAC that settled down spontaneously without consequences occurred in 2 cases; loss of sensitivity of the NAC in 4 patients; 1 patient developed haematoma. No asymmetry was reported. All women were clear of cancer after the treatment. Nipple-sparing mastectomy is the procedure of choice on selected patients.

Development of a solid-phase microextraction gas chromatography/tandem mass spectrometry method for polybrominated diphenyl ethers and polybrominated biphenyls in water samples.

Solid-phase microextraction has been applied for the first time to the determination of trace concentrations of some brominated flame-retardant compounds (BFRs) in water samples. For the development of the method, six polybrominated diphenyl ethers and two polybrominated biphenyls were considered as target analytes. The factors expected to influence the extraction process are fully discussed. Quantification has been performed by gas chromatography/tandem mass spectrometry using an ion trap mass analyzer. This is also the first time that tandem mass spectrometry is applied with these analytes. Unlike conventional methods for BFR analysis, which involve solvent extraction and several cleanup steps before gas chromatography, the proposed method uses headspace extraction and hard contamination of the chromatographic system is prevented. In addition, tandem mass spectrometry provides selectivity and sensitivity in the detection process. The method performs well achieving good linearity (R(2) > 0.997), precision, and detection limits (S/N = 3) ranging from 7.5 to 190 pg/L. The method has been applied to a variety of water samples.