Aspiration versus peritoneal lavage in appendicitis: a meta-analysis.

BACKGROUND: Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis. METHODS: According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate. RESULTS: Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%). CONCLUSIONS: This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Case of fake acute abdomen by metastatic melanoma.

Malignant melanoma is the neoplasm with highest probability of cardiac metastatization. Cardiac involvement by metastatic melanoma is rarely identified ante-mortem (5-30% of cases) for non-specificity of cardiac symptoms. In fact we show in this case report that abdominal pain can represent the predominant symptom. Furthermore we show the importance of linkage between clinical & anamnestic data which if underestimated can lead to an improper management and to the patient exitus.

Synchronous colorectal neoplasias: our experience about laparoscopic-TEM combined treatment.

Synchronous colorectal neoplasias are defined as 2 or more primary tumors identified in the same patient and at the same time. The most voluminous synchronous cancer is called "first primitive" or "index" cancer. The aim of this work is to describe our experience of minimally invasive approach in patients with synchronous colorectal neoplasias.Since January 2001 till December 2009, 557 patients underwent colectomy for colorectal cancer at the Department of General and Emergency Surgery of the University of Perugia; 128 were right colon cancers, 195 were left colon cancers while 234 patients were affected by rectal cancers. We performed 224 laparoscopic colectomies (112 right, 67 left colectomies and 45 anterior resections of rectum), 91 Transanal Endoscopic Microsurgical Excisions (TEM) and 53 Trans Anal Excisions (TAE). In the same observation period 6 patients, 4 males and 2 females, were diagnosed with synchronous colorectal neoplasias. Minimal invasive treatment of colorectal cancer offers the opportunity to treat two different neoplastic lesions at the same time, with a shorter post-operative hospitalization and minor complications. According to our experience, laparoscopy and TEM may ease the treatment of synchronous diseases with a lower morbidity rate.

The sigmoid volvulus: surgical timing and mortality for different clinical types.

BACKGROUND: In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types. METHODS: We realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group. RESULTS: In the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection. CONCLUSIONS: The mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmann's procedure is the proper operation to be considered.

Emergency treatment of complicated incisional hernias: a case study.

BACKGROUND: The emergency treatment of incisional hernias is infrequent but it can be complicated with strangulation or obstruction and in some cases the surgical approach may also include an intestinal resection with the possibility of peritoneal contamination. Our study aims at reporting our experience in the emergency treatment of complicated incisional hernias. METHODS: Since January 1999 till July 2008, 89 patients (55 males and 34 females) were treated for complicated incisional hernias in emergency. The patients were divided in two groups: Group I consisting of 33 patients that were treated with prosthesis apposition and Group II, consisting of 56 patients that were treated by performing a direct abdominal wall muscles suture. RESULTS: All the patients underwent a 6-month follow up; we noticed 9 recurrences (9/56, 16%) in the patients treated with direct abdominal wall muscles suture and 1 recurrence (1/33, 3%) in the group of patients treated with the prosthesis apposition. CONCLUSIONS: According to our experience, the emergency treatment of complicated incisional hernias through prosthesis apposition is always feasible and ensures less post-operative complications (16% vs 21,2%) and recurrences (3% vs 16%) compared to the patients treated with direct muscular suture.

A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy.

BACKGROUND: Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage. METHODS: We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage. CONCLUSION: The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Virtual colonoscopy in stenosing colorectal cancer.

BACKGROUND: Between 5 and 10% of the patients undergoing a colonoscopy cannot have a complete procedure mainly due to stenosing neoplastic lesion of rectum or distal colon. Nevertheless the elective surgical treatment concerning the stenosis is to be performed after the pre-operative assessment of the colonic segments upstream the cancer. The aim of this study is to illustrate our experience with the Computed Tomographic Colonography (CTC) for the pre-operative assessment of the entire colon in the patients with stenosing colorectal cancers. METHODS: From January 2005 till March 2009, we observed and treated surgically 43 patients with stenosing colorectal neoplastic lesions. All patients did not tolerate the pre-operative colonoscopy. For this reason they underwent a pre-operative CTC in order to have a complete assessment of the entire colon. All patients underwent a follow-up colonoscopy 3 months after the surgical treatment. The CTC results were compared with both macroscopic examination of the specimen and the follow-up coloscopy. RESULTS: The pre-operative CTC showed four synchronous lesions in four patients (9.3% of the cases). The macroscopic examination of the specimen revealed three small sessile polyps (3-4 mm in diameter) missed in the pre-operative assessment near the stenosing colorectal cancer. The follow-up colonoscopy showed four additional sessile polyps with a diameter between 3-11 mm in three patients. Our experience shows that CTC has a sensitivity of 83,7%. CONCLUSION: In patients with stenosing colonic lesions, CTC allows to assess the entire colon pre-operatively avoiding the need of an intraoperative colonoscopy. More synchronous lesions are detected and treated at the time of the elective surgery for the stenosing cancer avoiding further surgery later on.

[Virtual colonoscopy in stenosing colorectal cancer]. / Colonscopia virtuale nelle neoplasie stenosanti del colon-retto.

In 5-10% of patients it is not possible to achieve a complete endoscopic examination of the colon, because of obstructing cancer, excessive length of the colon, anatomical abnormalities or adhesions. Virtual colonoscopy is currently capable of investigating the colic lumen with a non-invasive technique, with high specificity and sensitivity. From January 2005 to July 2007 we treated 21 patients with obstructing neoplastic colorectal lesions, preventing a complete endoscopic examination. In all patients we performed a virtual colonoscopy, which revealed the presence of synchronous lesions (19%): a pedunculated polyp in two cases, a sessile polyp in one case and a right colonic vegetating lesion. In the 21 patients studied we performed a follow-up colonoscopy 3 months after the surgical treatment. No other endoluminal lesions were found, confirming the results of virtual colonoscopy. In our experience virtual colonoscopy presented 100% sensitivity and specificity. In this selected group of patients with obstructing lesions of the colon, virtual colonoscopy enables the surgeon to evaluate the entire colon, avoiding the execution of an intraoperative colonoscopy and possible surgical reintervention due to the finding of synchronous neoplastic lesions at postoperative follow-up endoscopy.

[Minimally invasive treatment of synchronous colorectal tumours]. / Trattamento mini-invasivo delle neoplasie sincrone del colon-retto.

In patients with colorectal cancers synchronous neoplastic lesions are an increasingly frequent finding at preoperative staging; 3% of the cases are other cancers while 33-35% of the synchronous lesions are villous adenomas. The treatment of most colorectal adenomas can be performed by endoscopic poplypectomy. In 5% of cases there are synchronous colorectal lesions also requiring surgical treatment. From January 1995 to June 2007 we treated 5 patients with rectal lesions by transanal endoscopic microsurgery (TEM) together with a laparoscopic colectomy for the presence of synchronous lesions at the "Clinica Chirurgica Generale e d'Urgenza" of the University of Perugia,. Surgical timing involved performing a sequential exeresis characterised by a cancer resection, followed by resection of the voluminous adenoma: TEM for rectal cancer followed by a laparoscopic right hemicolectomy with an extracorporeal anastomosis for a voluminous villous adenoma (1 patient) and laparoscopic right hemicolectomy with an extracorporeal anastomosis for cancer followed by TEM for a voluminous villous adenoma (2 patients). One patient with left colon cancer associated with a voluminous villous rectal adenoma first underwent TEM for the rectal adenoma and then a left laparoscopic hemicolectomy with an extracorporeal anastomosis in order to ease the transit of the circular mechanical stapler. Another patient with rectal and right colon adenomas first underwent TEM for a voluminous rectal sessile adenoma and later a right hemicolectomy. The use of this minimally invasive approach allowed rectum preservation and less invasive surgery.

Laparoscopic anterior gastropexy for chronic recurrent gastric volvulus: a case report.

INTRODUCTION: Gastric volvulus is an uncommon clinical entity, first described by Berti in 1866. It is a rotation of all or part of the stomach through more than 180 degrees . This rotation can occur on the longitudinal (organo-axial) or transverse (mesentero-axial) axis. This condition can lead to a closed-loop obstruction or strangulation. Traditional surgical therapy for gastric volvulus is based on an open approach. Here we report the case of a patient with chronic intermittent gastric volvulus who underwent a successful laparoscopic treatment. CASE PRESENTATION: A 34-year-old woman presented with multiple episodes of recurrent upper abdominal pain associated with retching and vomiting, treated unsuccessfully with intramuscular metoclopramide. Endoscopic examination of the upper digestive tract showed a suspected rotation of the stomach, and a chronic recurrent gastric volvulus was revealed by barium meal. The patient was operated on successfully, with an anterior laparoscopic gastropexy performed as the first surgical approach. CONCLUSION: Experience with laparoscopic anterior gastropexy is limited only to a few described cases. Our patient was clinically and radiologically followed-up for 2 years with no evidence of recurrence, either radiological or symptomatic. Based on this result, laparoscopic gastropexy can be seen and considered as an initial 'gold standard' for the treatment of gastric volvulus.